Transcript
Common Topics in Exam
• Acute Otitis Media
• Chronic Otitis Media
• Facial Nerve Paralysis
• Dizziness
• Head and Neck Masses
• Thyroidectomy and its complications
• Epiglottitis vs Croup
Acute Otitis Media
Inflammation of the Middle ear space
• 75 % of children have at least one episode by school age
• Peak age prevalence is 6-18 months
• Exposure to cigarette smoking from household contact is a known modifiable risk factor
Background
• Fever
• Recent onset of Ear pain (Irritability in pre-verbal children)
• Vomiting
• Lethargy
History
AOM continued
• Streptococcus Pneumoniae (40%)
• H. Influenza (30%)
• Moraxella ( Branhamella) Catarrhalis (20%)
Causative Organisms
• Inflammation
• Effusion
2 Cardinal features
• Bulging ear drum
• Haemorrhagic, injected or cloudy appearance
• Decreased movement on pneumatic otoscopy
Physical Examination
Otitis Media in Aboriginal Children
10 times more common among Aboriginal children than among non-Aboriginal children
8 out of 10 children will have middle ear infection and associated hearing loss at some time during school year
Hearing is thus important to learn during school life
AOM – Treatment
Pain relief / analgesics
• Short – term topical 2% lignocaine, 1-2 drops can be effective in severe pain
Need for antibiotics is controversial
• Many children with viral URTIs have mild reddening or dullness of the ear drum and antibiotics are not warranted in the absence of systemic features ( fever and vomiting)
• In contrast, where the eardrum is red or yellow and bulging with loss of anatomical landmarks, antibiotic therapy is warranted
Decongestants, anti-histamines and corticosteroids are not effective in AOM
Antibiotics Treatment
1st line
• Amoxicillin 45mg/kg/day if penicillin hyper-sensitivity : Cefaclor 10mg/kg oral TDS
2nd line
• Amoxicillin 80-90mg/kg/day(high dose)
• Amoxicillin+ Clavulanate 22.5+3.2mg/kg oral TDS
3RD Line
• Ceftriaxone 50-75mg/kg/day IV in 1-2 doses
• Clindamycin 10-30mg/kg/day oral TDS for 5-10days
Complications
Tympanic membrane perforation with otorrhea
• Most common suppurative complication of AOM and may be associated with intracranial complications
• Diagnosis
• Post-auricular inflammatory signs(erythema , oedema, tenderness or fluctuance)
• A protruding auricle/external auditory canal oedema
• Signs of AOM
• Treatment – IV antibiotics (flucloxacillin +3rd generation cephalosporin)
• ENT involvement is required and some cases may require surgical treatment
Acute Mastoiditis
AOM complications
• Otorrhea with TM perforation + transient hearing impairment.
• Usually resolves on itself with no long term effect of language or cognitive development
Otitis media with effusion
Facial nerve palsy secondary to AOM
Cholesteatoma
Chronic Suppurative Otitis Media
Causative organisms
Pseudomonas aeruginosa
Staphylococcus aureus
Proteus sp. E. coliBacteroides
fragilis
Infected otorrhea through tympanic membrane perforations
or tympanostomy tube
CSOM – Treatment
• Treatment
• Antipseudomonal penicillin(ciprofloxacin , levofloxacin , gentamicin) or cephalosporin ( children)
• Ear drops and quinolones (adults)
Safe vs Unsafe perforation
• Affects mucosa of the lower front part of the middle ear cleft(tubo-tympanic portion)
• Central perforation-always a rim of drum or annulus around the edge
• Involves the vibrating part of the TM – pars-tensa , below the malleolar folds at the level of the lateral process of the malleus
Safe
• Superior and/or posterior edge of TM perforation
• Perforation involves the fibrous edge or annulus of the tympanic membrane
• Associated granulation tissue
• White mass within middle ear seen through perforation
• Bone erosion
Unsafe
Cholesteatoma or chronic osteitis involves attic-antral portion
Cholesteatoma
Expanding lesions of the TEMPORAL bone composed of stratified squamous outer
epithelial lining and a desquamated keratin centre
Clinically defined as an abnormal extension of skin
into the middle ear and mastoid air cell spaces
Classification :
Congenital(embryonic rest of epithelium in anterior-
superior space)
Acquired(usually develops from retraction of pars
flaccid into prussak space, internal desquamation,
enzymatic erosion, osteitis)
Cholesteatoma
• Conductive hearing loss – from mass effect and erosion/discontinuity of ossicles
• Foul – smelling ear discharge
• Persistent otitis media
• Otalgia
• Vertigo
• Facial weakness
Presenting history
• TM retraction or perforation; seen with otoscopy
Examination
• CT scan(to determine the extent of spread) and audiogram ( for hearing loss)
Investigation
Cholesteatoma Treatment
Surgical removal -mastoid surgery with the aim of providing a safe, dry, waterproof and hearing ear. The procedure is performed through a postauricular incision under general anaesthetic.
Continuous monitoring to look out for recurrence
Complications of untreated CholesteatomaHearing loss
Facial nerve palsy
Dizziness
Subperiosteal Abscess
Meningitis
Brain abscess
Deafness and hearing loss
Deafness occurs at all ages but is more common in
elderly
One child in every 1000 is born with
significant hearing loss
People who have worked in high
noise levels (>85dB) are more than twice likely
to be deaf
Physical Examination
-Whisper Test
•Occlude the opposite ear, whisper “68” then “100” from a distance of 60cm
-Hair rubbing method
•If the sound is not heard, then a moderate hearing loss (40dB or greater)is likely
Physical examination
• Tuning fork tests : 512Hz
• Rinne test
• Compares a patient’s air and bone conduction hearing
• The tuning fork is struck and its stem is placed on the mastoid process, then approx. 2 in lateral to the opening of the external ear canal
• The patient reports if the tone sounds louder with the fork on the mastoid or just the ear canal
• Weber test
• Test for lateralisation
• The tuning fork is set into motion and placed on the midline of the patient’s skull
• The patient must state where the sound is heard louder: in the left or right or in the midline
• Formal Audiometry
Conductive vs Sensory Neural
Hearing loss
• Conductive Hearing loss is caused by an abnormality in the pathway conducting sound waves from the outer ear to the inner ear, as far as the footplate of the stapes
• Sensory Neural hearing loss is a defect in central to the oval window involving the cochlear(sensor), cochlear nerve(neural), or more rarely, the central neural pathways
•
Audiology
• An audiogram is indicated to evaluate any suspected hearing loss, tinnitus, vertigo and other ear symptoms.
• Screening for hearing loss in people regularly exposed to loud noises and for certain patients on ototoxic medications (e.g. gentamicin).
• an audiological assessment should be performed for any child if there is concern about hearing or speech, developmental delay or difficulties at school.
• Children with known hearing loss should have regular (at least yearly) hearing evaluations as the hearing loss may be progressive.
Audiogram
• Audiograms are safe and has no contraindications
• Report of an Audiogram
• There is a key to the symbols used on the report (Figure 1). The right ear is written in red, and the left in blue, although printed reports are in black. The basic symbols are:
• O air conduction right ear
• X air conduction left ear
• [ bone conduction right ear
• ] bone conduction left ear.
• An easy way to remember which ear is which is: ‘right-O’ and to imagine the patient sitting opposite with their ears [ ] facing you.
Interpretation Results
• The audiogram graph axes are intensity and pitch.
• There are four lines plotted – each ear is tested and reported separately for bone and air conduction. The threshold of hearing is reported for each ear and represents the softest pure tone sound that is heard.
• The vertical (‘y’) axis shows the intensity (loudness) of the test sounds in decibels (dB). The loudness scale is from very soft (–10 dB or 0 dB) at the top of the chart to very loud (110 dB) at the bottom of the chart. This range is vast: a sound that is just audible is 0 dB, a soft voice at 30 dB is 1000 (103 ) times louder, and a sound at 120 dB is 1012 louder.
• The horizontal (‘x’) axis shows the frequency (pitch) of each sound.
• Like a piano, the low frequency sounds are on the left side of the graph and the high frequency sounds are on the right.
• The human ear can hear from 20–20 000 Hz, but the most important range for understanding speech is from 250 Hz to 8 KHz, so this is the focus of testing
Audiogram
• The threshold of hearing :
• Air conduction thresholds show the softest sound the patient hears when this sound is transmitted through headphones over the ears. Alternatively, if the ear canals collapse, tube phones that sit inside the external canal may be used. This is indicated on the audiogram as ‘TP’. Air conduction measures the hearing through the external, middle and inner ears. Bone conduction thresholds show the softest sound heard when a vibrator is held on the mastoid bone and vibrations are carried through the soft tissues and bone directly to the cochlea. Discrepancies between the air and bone conduction usually indicate pathology in the external ear canal or middle ear blocking the normal transmission of sound to the cochlea. Sound passes to both cochleae through the bone, so the patient may have difficulty determining in which ear the sound is heard. Also, a loud sound presented by air conduction to one ear may be heard in the other ear, and so if the ear thresholds differ by more than 40 dB the better ear must be masked. Narrow band sound is passed through the headphone to the better ear, and the patient is instructed to respond only to the sound in the test ear. This may be difficult for some patients to understand, especially young children.
Impedance audiometry
• Assessment of the status of the TM and middle ear via tympanometry
• Air pressure is lowered and raised in external ear to understand how does TM reacts to it
• A normal tympanogram is ‘type A’.
• Pathology of the middle ear will often have a type B tympanogram with a low volume if there is a middle ear effusion and a high volume if there is a perforation or patent middle ear ventilation tube.
• A type C tympanogram has a peak at sub atmospheric pressure and indicates poor eustachian tube function. Impedance audiometry also assesses acoustic reflex pathways, which include the cochlea and facial nerves and the auditory brainstem
Tinnitus
Complaint of noises in the ears in the absence of a sound stimulus
Not a disease but a symptom
Exact cause is unknown but is though to be due to inappropriate activity in the hair cells of the cochlea
Subjective Tinnitus(Only heard by the patient/common)
• Presbycusis - Hyper/hypothyroidism
• Noise-induced hearing loss - Hyperlipidaemia
• Otitis media with effusion -Vitamin A , B, Zinc deficiency
• Meniere’s disease
• Otosclerosis - Neurologic
• Cerumen - Head trauma
• Foreign body against TM - Multiple Sclerosis
Otologic - Metabolic
• ASA - Psychiatric
• NSAIDs - Anxiety
• Aminoglycosides - Depression
• Antihypertensives
• Heavy metas
Drugs - CPA tumours
Objective Tinnitus(can be heard by others/rare)
• Vascular - Mechanical
• Benign Intracranial hypertension -Patulous eustachian tube
• Arteriovenous malformation -Palatal myoclonus
• Glomus tympanicum -Stapedius Muscle spasm
• Glomus Jugular
• Arterial bruits
• High-riding carotid artery
• Vascular loop
• Persistent stapedial artery
• Venous Hum:
• Carotid stenosis
• High jugular bulb
• Hypertension
• Hyper/hypothyroidism
Tinnitus
Good history and thorough physical examination
• Audiological examination by audiologist
• Tympanometry and speech discrimination
• MRI(If serious cause suspected)
Investigations
• Treat any underlying cause and aggravating factors. Otherwise, minimise symptoms.
• Educate and reassure the patient(tinnitus is nearly always amenable to treatment)
• Holistic approach
• Relaxation techniques
• Tinnitus retraining therapy
• Cognitive behavioural therapy
• Background noise /Tinnitus maskers
• Hearing aids(based on audiologist assessment)
Management
Tinnitus
• Clonazepam 0.5mg nocte
• Minerals(e.g. Zinc and Mg)
• Betahistine(Serc) 8-16mg daily (max 32mg)
• Carbamazepine
• Antidepressants
Medical
• Lignocaine 1% IV slowly(up to 5ml)
Acute Severe tinnitus
Facial Nerve Paralysis
• Supranuclear and nuclear(UMN)
• Vascular lesion i.e. stroke
• Intracranial tumours
• Multiple sclerosis
• Infranuclear (LMN)
• Bell’s palsy
• Trauma(Birth injury, fractured temporal bone, surgical)
• Tumours( parotid tumours, acoustic neuroma, malignant disease of the middle ear)
• Middle ear suppuration(Acute or chronic otitis media)
• Ramsay hunt syndrome
• Guillain –Barre syndrome
• Sarcoidosis
Bell’s Palsy
• Sudden(within 48 hours or less) facial paralysis, which leads to the loss of facial expression
• It is the most common cause of facial paralysis or weakness of the facial nerve( Cranial nerve 7)
• Usually SPONTANEOUS recovery
• Can be unilateral or rarely bilateral
Definition and overview
• Unknown
• Some cases – Viral prodrome : HSV is the infecting agent
• May be caused by local inflammation or ischemia, resulting in nerve constriction
Aetiology
Bell’s Palsy
• Rare in children
• More common to occur during 35-45 years of age
Incidence
• Bell’s palsy is a diagnosis of exclusion
• Can be transient or permanent and can affect all or any of the branches of the facial nerve
• Facial muscles: Inability to control facial muscles on the affected side (WITHIN a 48 hour onset)
• EYE : Affected side CANNOT VOLUNTARILY BE CLOSED. Can lead to blurred vision. Lacrimation and salivation can be affected
• Taste : Anterior 2/3rd sensation of the tongue may be IMPAIRED
• Posterior auricular pains or otalgia can occur
• Cheek or mouth : Tingling or numbness
Clinical Features
Bell’s Palsy
Workup
•There are no specific diagnostic tests to confirm Bell’s palsy
•Evaluate Middle ear infection or effusion, as this may be the underlying cause for facial paralysis
•Refer the patient to an OPTHALMOLOGIST for a full eye examination
Treatment
•Spontaneous recovery occurs in most cases with or without treatment
•Pharmacology : ONCE Dx is confirmed by exclusion ; Goal is to initiate therapy within 3 days or less of symptom onset
•Corticosteroids : Increases probability of facial nerve function recovery , lessens chance for synkinesis
•Antiviral Therapy : Should not be used as monotherapy
•Corticosteroids + antiviral therapy
Note : Role of antiviral therapy has not been fully established and if there is a benefit ,it is likely modest at best
Bell’s Palsy
• Preventing eye complications
• such as Corneal dryness
• Over the counter topical ocular lubricants
• Wear glasses indoors and outdoors to reduce exposure to dry winds and sun
• Apply ocular lubricating ointments at night
• Wear a patch or tape the eyes shut at night to prevent dryness
• Improve the function of any cranial nerve deficits, particularly the facial nerve and prevent or reduce permanent damange
Dosing recommendations
• Prednisone : 1mg/kg/day(Max 80mg) in divided doses for 7 days
• Valtrex(Valacyclovir) : 1000 mg TID for 7 days, or
• Famvir( Famciclovir) : 750mg TID for 7 days
• Note : Caution when using famciclovir – it can cause a transitory rise in hepatic enzyme production
Ramsay Hunt Syndrome
Also called as Herpes Zoster Oticus is an infection where the varicella zoster virus that reactivates from its latent state in the facial nerve and can also affect the vestibulocochlear nerve(8th nerve)
Note : In order to accurately dx herpes zoster oticus , the patient must report a previous history of having chicken pox
When herpes zoster oticus is associated with facial paralysis, the infection is called Ramsay Hunt Syndrome.
Ramsay Hunt Syndrome
More common in older adults or the immunosuppressed
Exacerbating factor include physical and emotional stress
Corticosteroids
• Systemic corticosteroids are used to relieve pain and decrease vertigo due to inflammation that may be affecting 8th nerve
• There is no evidence that indicates corticosteroids prevent the development of postherpetic neuralgia
Corticosteroid + anti-viral therapy
• Patients treated with acyclovir + prednisone had better outcomes(time to healing of rash , time to cessation of acute neuritis , time to return to usual activity and sleep , and time to cessation of analgesics) than those treated with either prednisone or acyclovir alone
Dosing recommendations
Prednisone : 1mg/kg/day in divided doses for 7 days, a gradual taper during the second week optional
Valtrex(valacyclovir): 1000mg TID for 7 days or
Famvir( Famciclovir) : 750mg TID for 7 days
Note : Caution when using famciclovir – it can cause a transitory rise in hepatic enzyme production.
Dizziness
Dizziness is a term that describes an impairment of spatial perception and stability
The term can be various such as vertigo, off balance, dis-equilibrium, giddiness, spinning and light-headedness
When evaluating a patient with dizziness, the most important question during history taking “How long does the dizziness symptom last ?” This will help narrow down the likely cause
Dizziness
Vestibular testing evaluates the vestibular system and distinguishes among possible peripheral causes while suggesting whether or not a central cause of dizziness exists
The peripheral part evaluates the inner ear balance organs or labyrinth and the vestibular nerves such as BPPV, Labyrinthitis and Vestibular neuritis
The central part evaluates the vestibular nuclei in the brainstem and its numerous connections to the cerebellum and higher centre Such as Multiple Sclerosis and other demyelinating diseases, Vascular disease and stroke.
When carrying out an initial assessment try to divide the symptoms into:
• inner ear disorder or peripheral vestibular •
• brain disorder (brainstem or vestibulocerebellum) or central vestibular
• Both
• Neither
Duration of Vertigo as a dx indicator
SECONDS — BENIGN POSITIONAL VERTIGO
MINUTES —CEREBROVASCULAR
ISCHAEMIAE
HOURS — MENIERE’S DISEASE
DAYS — VIRAL LABYRINTHITIS
BPPV
Most common cause of Vertigo
Affects all ages Approx. 50% of people over the age of 70 have experienced at least one episode
Aetiology:
Caused by sediment, such as otoconia(calcium carbonate crystals) that have become free floating within the inner ear
When the patient turns his or her head quickly , the free-floating materials moves the balance canal fluid(endolymph) in the inner ear and stimulates the vestibular division of the 8th cranial nerve
BPPV
Vertigo usually begins after a latent period
of 5-10 seconds
following the change in
head position
Duration of vertigo lasts seconds(10-60seconds)
then subsides rapidly
May be associated with closed head injury , infections,
surgery and prolonged bed
rest
Pathognomonic sign:
Nystagmus toward the affected ear on doing a
Dix-Hallpike test
Treatment
Epley repositioning manoeuvre
Brandt-Daroff exercises
Vestibular Neuritis
Second most common disorder
affecting the labyrinth
Viral aetiology with consequent inflammation of
the vestibular nerve
Frequently associated recent
flu symptoms
Signs/Symptoms:
Sudden onset of severe rotatory vertigo
Nausea and Vomiting
Spontaneous nystagmus and
diminished Vestibulo-ocular reflex
Hearing loss absent
Vestibular Neuritis
DDx : Cerebellar haemorrhage and infarction
Labyrinthitis refers to the simultaneous loss of hearing and balance in the affected ear, Tinnitus present. Occurs due to change in head position
Treatment
• Bed rest , Vestibular sedatives and anti-emetics in the first 24-72 hours
• Dimenhydrinate
• Prochlorperazine
• Diazepam
• Short tapering course of oral steroids
• Vestibular adaptation exercises/rehabilitation in the recovery phase
Meniere’s Disease
Is an inner ear disorder
Common in 35-50 age group
When the syndrome is idiopathic and not attributable to other causes(i.e. syphilis) it is referred to as Meniere’s disease
Characterised by
•Vertigo : duration from 20-30mins up to a few hours
•Tinnitus : 91.1 %
•Nausea and vomiting
• Ipsilateral hearing loss (87.7%) progressive - SNHL
•Sweating and pallor
•Diplacusis(43.6%) – Difference in perception pitch between the ears
•Recruitment(56%) – Rapid growth of perceive loudness with increasing stimulus level
Treatment
• Vestibular sedative, antiemetic for acute episodes
• Prochlorperazine – nausea and vomiting
• Diazepam – for anxiety
• Low salt diet+/- diuretic for maintenance treatment
• Vasodilators : Beta-histine
• Meniette device : Self- administered TID, Each treatment is three 1-min cycles, applies intermittent alternating pressure 0-20cm H2O, Requires a tympanostomy tube
• Intra-tympanic therapy – steroids , aminoglycosides
• Surgery for refractive cases
Management
In the early stages - Medical management :
• strict low salt diet sometimes with the addition of a diuretic, is the mainstay of treatment.
• Betahistine hydrochloride (Serc) are often used but there is insufficient evidence to say whether betahistine has any effect on Meniere’s disease.
Surgical intervention :
• When medical management is insufficient - labyrinthectomy ;division of the vestibular nerve and various operations on the endolymphatic sac are prescribed.
Affected inner ear infusion with GENTAMICIN – decreases production of hormone saacin, is said to be most likely success.
https://www.racgp.org.au/afpbackissues/2002/200208/20020801tonkin2.pdf
Acoustic Neuroma
• Vestibular schwannoma -80% of all cerebellopontine angle tumors
• 0.8% to 2.7% of population : 0.7 to 1 percent per 100,000
• Pathology : vestibular division of cranial nerve VIII ; Schwann cells
• Type 2 Neurofibromatosis
• Bilateral tumours
• Chromosome 22 abnormality
• Autosomal Dominant transmission
Symptoms
Unilateral progressive SNHL 85%
Sudden hearing loss 15 %
Tinnitus 56%
Vertigo 19%
Midface hypesthesia, cranial nerve V
Facial paresis
Diplopia, dysphagia, hoarseness, aspiration, cerebella ataxia
Hydrocephalus : headache and vomiting
Treatment
• Observation
• 50-55% show little or no growth in 1-3 years
• Less than 0.2mm per year
• Repeat MRI to monitor growth
• Surgical resection
• Trans labyrinthine, middle fossa, or suboccipital retro sigmoid approaches
• Stereotactic radiosurgery (gamma knife)
Neck swelling Anterior and Posterior Triangle
MIDLINE
• Thyroid nodule (moves upon swallowing)
• Thyroglossal cysts (moves upwards on tongue protrusion)
• Dermoid cyst (beneath chin)
ANTERIOR TRIANGLE
• Branchial cyst (in upper part):
• – usually adulthood (20–25 years)
• Carotid body tumour:
• – opposite thyroid cartilage
• – smooth and pulsatile
• – can be moved laterally but not vertically
• – usually 40–60 years
• – requires excision (with care)
• Carotid aneurysm
• Lateral thyroid tumours
POSTERIOR TRIANGLE
• Developmental remnants:
• – cystic hygroma
• – branchial sinuses and cysts
• Pancoast tumour (from apex lung)
• Cervical rib
WIDESPREAD
• Sebaceous cysts
• Lipomas
Cystic Hygroma
• Commonly involves the posterior cervical space
• May be macrocystic or microcystic
• MRI is the gold standard for Radiological Evaluation
Branchial Cleft Cysts
• Most common cystic lesion of the anterior triangle of the neck in children
• Unilocular, cystic mass displacing the submandibular gland anteriorly and the sternocleidomastoid muscle posteriorly
Thyroglossal Duct Cyst
• Midline lesion anywhere from foramen caecum and the thyroid gland
• Moves with protrusion of the tongue
• May contain ectopic thyroid tissue
• May contain all of the functioning thyroid
• Ultrasound, thyroid scans
• Surgical excision – Sistrunk procedure
Cervical Lymph nodes
• Consistency of enlarged nodes
• Rules of thumb are:
• hard: secondary carcinoma
• rubbery: lymphoma
• soft: sarcoidosis or infection
• tender and multiple: infection
Malignant Masses
Primary malignancies : Thyroid, salivary, lymphomas and sarcomas
Risk Factor for mucosal(oral cavity, larynx,pharynx) head and neck cancer”
• Chronic sun exposure
• Tobacco
• Alcohol use
• Poor dentition
• Industrial or environmental exposures
• Family history
Metastatic
• METASTATIC
• Check mouth, pharynx, sinuses, larynx, scalp, oesophagus, stomach, breast, lungs, thyroid and skin.
• A working rule is upper neck—from skin to upper aerodigestive tract; lower neck—from below clavicles (e.g. lung, stomach, breast, colon).
• Examples:
• – occipital or pre-auricular—check scalp
• – submental—check mouth, tongue, teeth
• – submandibular—check floor of mouth
• – left supraclavicular (under sternomastoid)—consider stomach (Troisier sign)
• – deep anterior cervical—consider larynx, thyroid, oesophagus, lungs
Neck Masses
• Management
• Fine needle aspiration and biopsy
• For neck masses persists beyond 4-6 weeks , size more than 3cm, location in supraclavicular fossa
• CT scan
• Best imaging technique for evaluating a neck mass
According to Age
• The age of the patient is a helpful guide, as causes of neck lumps can be roughly categorised by the ‘20:40 rule’:
• 0–20 years: congenital, inflammatory, lymphoma, tuberculosis
• 20–40 years: inflammatory, salivary, thyroid, papillary thyroid cancer, lymphoma
• >40 years: lymphoma, metastases, i.e. neck lumps are malignant until proven otherwise
Oesophageal Carcinoma
• Symptoms and signs
• Dysphagia is the most common symptoms
• Initially manifests as dysphagia to solids eventually to liquids as well
• Weight loss in more than 50% of patients
• Hoarseness is usually due to invasion of the right or left recurrent laryngeal nerve , with paralysis of the ipsilateral vocal cord
• Regurgitation and aspiration may occur as well as development of tracheooesophageal fistula
Oesophageal Carcinoma
• Barium swallow
• Shows both the location and the extent of the tumour
• Irregular intraluminal mass or a stricture
Imaging studies
• Allows direct visualization and biopsy of the tumour
• For tumours of the upper and mid-oesophagus ; bronchoscopy is indicated to rule out invasion of the tracheobronchial tree
Endoscopy
• Surgical- Oesophageal resection/esophagectomy
• Non-surgical – Radiation therapy and chemotherapy, stents, laser therapy
Treatment
Laryngeal Carcinoma
• Supraglottic -40%
• Glottic- 59%
• Subglottic -1%
Incidence of laryngeal cancer by
• Hoarseness, dysphagia, hemoptysis , mass in the neck, throat pain , ear pain, airway compromise and aspiration
Clinical findings
Neck examination
Imaging : CT scan, PET(Positron Emission tomography), MRI ,
Invasive investigation : Laryngoscopy
Assessment of nutritional status
Laryngeal Carcinoma
• Clinical Findings
• Laboratory findings and special tests
• Biopsy
• Chest imaging – Cxray , CT scan
• Bronchoscopy with cytological evaluation of bronchial washings, transbronchial biopsy
• Oral and Neck examination and further neurological examination (cranial nerves)
Laryngeal Carcnioma
• Treatment
Surgical treatment
• Microlaryngeal surgery
• Hemilaryngectomy
• Supraglottic laryngectomy
• Supracricoid laryngectomy
• Near-total laryngectomy
• Total laryngectomy
Hoarseness
• Any patient over 45 years of age with unexplained, persistent hoarseness(>3 weeks)should be referred to a specialist for further investigation OR any person who has Hoarseness and following red flags:
• Significant smoking history
• Otalgia
• Dysphagia / odynophagia
• Stridor
• Haemoptysis
• Fevers / night sweats / weight loss
• Neck mass
• Refer to otolaryngologist
Viral Parotitis
• Acute, bilateral swelling accompanied by pain, erythema, tenderness, malaise and fever
• Peak incidence in children aged 4-6 years
• 14-21 days incubation period
• Disease is contagious
• Self-limiting and treatment is symptomatic
Disease of the salivary gland
• Acute painful swelling of the glands with fever
• Risk factors: dehydration, trauma, immunosuppression and debilitation
• Skin overlying the gland may be warm, tender and erythematous
• Saliva from the affected gland must be cultured
• May also have purulent ductal discharge
Sialadenitis
• Rehydration
• IV antibiotics
• Warm compresses
• Sialagogues(promotes secretion of saliva)
• Oral hygiene
• Incision and drainage
Treatment
Diseases of the salivary gland
• Acute painful swelling of the salivary gland(usually submandibular gland) which may be recurrent
• Aggravation of symptoms with eating swelling subsides after approx. 1 hour
• A stone may be palpated
• Treatment depends on the location of the calculus
Sialolithiasis
• X-ray : Lateral , occlusal , intra-oral views
• Sialography : most accurate method
• CT scan
• USD not proven useful
Imaging:
Diseases of the salivary
gland
• Treatment of sialolithiasis
• Intraoral extracting
• Surgical excision
• Endoscopic techniques
• Other measures : basket extraction under radiologic guidance , lithotripsy
MCQ
• The parents of a 6 years-old was brought her to your clinic after they noticed a swelling on the midline of her neck. On examination the swelling moves with protruding the tongue.She is otherwise healthy and is gaining weight appropriately. Which one of the following should not be considered as a diagnosis in this child?
• A Acute cervical adenitis.
• B Branchial cleft cyst.
• C Cystic hygroma.
• D Sternocleidomastoid muscle hematoma.
• E Thyroglossal duct cyst
MCQ
• The parents of a 6-week-old baby has brought her to your clinic after they noticed a swelling on the right side of her neck. She is otherwise healthy, is being breastfed, and is gaining weight appropriately. Which one of the following should not be considered in the differential diagnosis of the lateral cervical swelling in this child?
• A Acute cervical adenitis.
• B Branchial cleft cyst.
• C Cystic hygroma.
• D Sternocleidomastoid muscle hematoma.
• E Thyroglossal duct cyst
MCQ
• Old man 60 years old who is a heavy smoker for 40 years comes to you with a swelling in the tonsillar region. O/E there is a mass in the tonsillar pouch, what is your diagnosis ?
• a. Nasopharyngeal cancer
• b. Lipoma
• c. lymphoma
• d. laryngeal cancer
• e. metastatic spread
MCQ
• Old man 60 years old who is a heavy smoker for 40 years comes to you with a swelling in the tonsillar region. O/E there is a mass in the tonsillar pouch, what is your diagnosis ?
• a. Nasopharyngeal cancer
• b. Lipoma
• c. lymphoma
• d. laryngeal cancer
• e. metastatic spread
MCQ
• Woman with subtotal thyroidectomy ,in post op room , 12 hrs, got difficulty breathing ,stridor, drain tube collection is few, what to immediately?a. Remove deep muscle sutureb. Remove skin staplesc. Intubationd. Oxygen via mask
• E. Take to OT for surgery
MCQ
• Woman with subtotal thyroidectomy ,in post op room , 12 hrs, got difficulty breathing ,stridor, drain tube collection is few, what to immediately?a. Remove deep muscle sutureb. Remove skin staplesc. Intubationd. Oxygen via mask
• E. Take to OT for surgery
MCQ
• A 56-year-old woman presents to her primary care physician for dizziness. She says that her symptoms began approximately 1 month prior to presentation and are associated with nausea and ringing of the ears. She describes her dizziness as a spinning sensation that has a start and end and lasts approximately 25 minutes. This dizziness is severe enough that she cannot walk or stand. Her symptoms are fluctuating, and she denies any tunnel vision or feelings of fainting. However, she has abruptly fallen to the ground in the past and denied losing consciousness. Medical history is significant for a migraine with aura treated with zolmitriptan, type 2 diabetes managed with metformin, and hypertension managed with lisinopril. Her blood pressure is 125/75 mmHg, pulse is 88/min, and respirations are 16/min. On physical exam, when words are whispered into her right ear, she is unable to repeat the whispered words aloud; however, this is normal in the left ear. Air conduction is greater than bone conduction with Rinne testing, and the sound of the tuning fork is loudest in the left ear on Weber testing. Which of the following is most likely the diagnosis?
1 Benign paroxysmal positional vertigo2 Meniere disease3Acoustic neuroma4 Transient ischemic attack5 Vestibular neuritis
MCQ
• .A 56-year-old woman presents to her primary care physician for dizziness. She says that her symptoms began approximately 1 month prior to presentation and are associated with nausea and ringing of the ears. She describes her dizziness as a spinningsensation that has a start and end and lasts approximately 25 minutes. This dizziness is severe enough that she cannot walk or stand. Her symptoms are fluctuating, and she denies any tunnel vision or feelings of fainting. However, she has abruptly fallen to the ground in the past and denied losing consciousness. Medical history is significant for a migraine with aura treated with zolmitriptan, type 2 diabetes managed with metformin, and hypertension managed with lisinopril. Her blood pressure is 125/75 mmHg, pulse is 88/min, and respirations are 16/min. On physical exam, when words are whispered into her right ear, she is unableto repeat the whispered words aloud; however, this is normal in the left ear. Air conduction is greater than bone conduction with Rinne testing, and the sound of the tuning fork is loudest in the left ear on Weber testing. Which of the following is most likely the diagnosis?
• 1 Benign paroxysmal positional vertigo2 Meniere disease3Acoustic neuroma4 Transient ischemic attack5 Vestibular neuritis
MCQ
• 4year boy presents with fever, sore throat and lymphadenopathy. The dx of tonsillitis has been made. He missed 2 weeks of his school. What is the most appropriate management for this patient?a. Tonsillectomyb. Paracetamol/ibuprofenc. Oral penicillin Vd. IV penicilline. PCM/NSAIDS
MCQ
• 4year boy presents with fever, sore throat and lymphadenopathy. The dx of tonsillitis has been made. He missed 2 weeks of school. What is the most appropriate management for this patient?a. Tonsillectomyb. Paracetamol/ibuprofenc. Oral penicillin Vd. IV penicilline. PCM/NSAIDS
MCQ
• 5year old girl presents with fever, sore throat and lymphadenopathy. The dx of tonsillitis has been made. She had 3 episodes of tonsillitis last year. What is the most appropriate management for this patient?a. Tonsillectomyb. Paracetamol/ibuprofenc. Oral penicillin Vd. IV penicilline. PCM/NSAIDS
MCQ
• 5year old girl presents with fever, sore throat and lymphadenopathy. The dx of tonsillitis has been made. She had 3 episodes of tonsillitis last year. What is the most appropriate management for this patient?a. Tonsillectomyb. Paracetamol/ibuprofenc. Oral penicillin Vd. IV penicilline. PCM/NSAIDS
Guidelines for Tonsillectomy
• Repeated attacks of acute tonsillitis
• Enlarged tonsils and/or adenoids causing airway obstruction, including OSA
• Chronic tonsillitis
• More than one attack of peritonsillar abscess
• Biopsy excision for suspected new growth
Criteria for Recurrent Tonsillitis
• 7 infections in 1 year
• >2 weeks missed from school
• 5 infections/ year for 2 consecutive years
• 3 infections/year for 3 consecutive years
MCQ
• 65 year of age patient ringing both ear symptoms started 12 month ago; symptoms more on left then rt .there is no hearing loss; Webber & Rinne’s test all normal. what next?a) audiometryb) tonometry.c) provocative audiometryd) USD of carotid vesselse) MRI brain
MCQ
• 65 year of age patient ringing both ear symptoms started 12 month ago; symptoms more on left then rt .there is no hearing loss; Webber & Rinne’s test all normal. what next?a) audiometryb) tonometry.c) provocative audiometryd) USD of carotid vesselse) MRI brain
MCQ
• Left sided swelling anteriorly of left ear in 45 years old man. Swelling is fixed with muscles. The man spitted blood stained sputum and is a heavy smoker. He cannot close his mouth properly on the affected side. Dx:A. Parotid pleomorphic adenomaB. Parotid carcinomaC. Metastatic lung cancerD. Cancer in lateral of tongueE. Carcinoma larynx
MCQ
• Left sided swelling anteriorly of left ear in 45 years old man. Swelling is fixed with muscles. The man spitted blood stained sputum and is a heavy smoker. He cannot close his mouth properly on the affected side. Dx:A. Parotid pleomorphic adenomaB. Parotid carcinomaC. Metastatic lung cancerD. Cancer in lateral of tongueE. Carcinoma larynx
MCQ
40 years old alcoholic and smoker complains of a 2 cm painless lump on the left tonsil. No other signs and symptoms described. What is the most likely diagnosis?a. Squamous cell carcinomab. Nasopharyngeal cancerc Aneurysm on the carotid arteryd. Metastatic from lunge. Non-Hodgkin lymphoma
MCQ
40 years old alcoholic and smoker complains of a 2 cm painless lump on the left tonsil. No other signs and symptoms described. What is the most likely diagnosis?a. Squamous cell carcinomab. Nasopharyngeal cancerc Aneurysm on the carotid arteryd. Metastatic from lunge. Non-Hodgkin lymphoma
8 month old baby, parents concerned not babbling yet. Appears to respond well to sounds on examination. MX?a) tell its normal variantb) review in 6 monthc) arrange speech pathologist referrald) ENT consult
e) Blame mother
MCQ
8 month old baby, parents concerned not babbling yet. Appears to respond well to sounds on examination. MX?a) tell its normal variantb) review in 6 monthc) arrange speech pathologist referrald) ENT consult
e) Blame mother
MCQ
• A 10yo girl has been referred for assessment of hearing as she is finding difficulty in hearing her teacher in the class. Her hearing tests show: BC normal, symmetrical AC threshold reducedbilaterally, weber test shows no lateralization. What is the single most likely dx?a. Chronic perforation of tympanic membraneb. Chronic secretory OM with effusionc. Congenital sensorineural deficitd. Otosclerosise. Presbycusis
MCQ
A 10yo girl has been referred for assessment of hearing as she is finding difficulty in hearing her teacher in the class. Her hearing tests show: BC normal, symmetrical AC threshold reducedbilaterally, weber test shows no lateralization. What is the single most likely dx?a. Chronic perforation of tympanic membraneb. Chronic secretory OM with effusionc. Congenital sensorineural deficitd. Otosclerosise. Presbycusis
MCQ
• .A 30 year old man with parotid gland swelling increases while having food. What is the investigation of choice?A. Salivary gland biopsyB. CTC. MRID. Sialography
• E. X-ray
MCQ
• A 30 year old man with parotid gland swelling increases while having food and dry mouth and dry eyes. What investigation to be done?A. Salivary gland biopsyB. CTC. MRID. Sialography
• E. X-ray
MCQ
Pic of submandibular swelling of man. Has history of joint pain and dry eye and dry mouth for 8yrs ago, Next investigation?A. anti nuclear antibodyB. FNACC. CT head and neckD. USE. excisional biopsy
MCQ
• Pic of submandibular swelling of man. H/O of joint pain and dry eye and dry mouth for 8yrs ago. What is the next investigation?A. anti nuclear antibodyB. FNACC. CT head and neckD. USE. excisional biopsy
MCQ
• 4. Pic of an old man with immovable submandibular lump attached to the fascia. Old man with dry eyes.a. ANAb. CT scan of head and neckc. FNA
• D. x-ray
• E. USD
MCQ
• 4. Pic of an old man with immovable submandibular lump attached to the fascia. Old man with dry eyes and joint pain.a. ANAb. CT scan of head and neckc. FNAC
• D. x-ray
• E. USD
MCQ
• Aboriginal child comes with left side green purulent ear discharge and nasal discharge for 7 weeks and his right ear has dull retracted TM. What is most appropriate step :a) Amoxicillin b)ear toiletc)prednisoloned)reassure
• e)Community awareness
MCQ
• Aboriginal child comes with left side green purulent ear discharge and nasal discharge for 7 weeks and his right ear has dull retracted TM. What is most appropriate step :a) Amoxicillin b)ear toiletc)prednisoloned)reassure
e)Community awareness
MCQ
• A women with recurrent dizziness and vertigo every month. What’s the most important step in management?
• EEG
• CT scan
• Reassure it will be gone
• ENT referral
• Menstrual Vertigo
MCQ
• A girl with recurrent dizziness and vertigo every month. What’s the most important step in management?
• EEG
• CT scan
• Reassure it will be gone
• ENT referral
• Menstrual Vertigo
MCQ
3yr indigenous child with profuse yellow colour discharge, nasal green discharge, inflamed TM, enlarged inflamed tonsils for 1 week brought my mother to your clinic. What is your next step?- Oral Amoxil-Tobramycin ear drops-Ear toilet-Oral steroid-Do nothing
MCQ
• 3yr indigenous child with profuse yellow colour discharge, nasal green discharge, inflamed TM, enlarged inflamed tonsils for 1 week brought my mother to your clinic. What is your next step?- Oral Amoxil-Tobramycin ear drops-Ear toilet-Oral steroid-Do nothing
MCQ
A boy came to you with history of ear discharge 2 weeks ago, his tympanic membrane looks dull and retracted and there is yellow discharge from his ear. Next step in management?- Oral Amoxicillin- Ear toilet
- Analgesics
- Aware community
- Admit to hospital
MCQ
A boy came to you with history of ear discharge 2 weeks ago, his tympanic membrane looks dull and retracted and there is yellow discharge from his ear. Next step in management?- Oral Amoxicillin- Ear toilet
- Analgesics
- Aware community
- Admit to hospital
MCQ
• 7 year boy last 2 year has difficulty in writing and school home work. previously his school grade was good but now he is having some problem. Parents are very worries about his performance at school and so are his teachers. what will help for further assessment?a. Opthalmological assessmentb. Audiological assessmentc. Family dynamicsd. Phychiatric assessment.
• E. Talking to friends and teachers
MCQ
• 7 year boy last 2 year has difficulty in writing and school home work. previously his school grade was good but now he is having some problem. Parents are very worries about his performance at school and so are his teachers. what will help for further assessment?a. Opthalmological assessmentb. Audiological assessmentc. Family dynamicsd. Phychiatric assessment.
• E. Talking to friends and teachers
MCQ
• 19. 8 months old baby, parents concerned not babbling yet. But he appears to respond well to sounds on examination. What is the best Management for this child ?a) tell its normal variantb) review in 6 monthsc) arrange speech pathologist referrald) ENT consult
• e) Audiometry consult
MCQ
• 19. 8 months old baby, parents concerned not babbling yet. But he appears to respond well to sounds on examination. What is the best Management for this child ?a) tell its normal variantb) review in 6 monthsc) arrange speech pathologist referrald) ENT consult
• e) Audiometry consult
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