Zaid Awad

MBChB MRCSEd MRCSEng DOHNS Specialty Registrar in Otolaryngology, Head and Neck Surgery, London

Imperial College Healthcare NHS Trust

Clinical Research Fellow Department of Surgery and Cancer

Imperial College of Science, Technology and Medicine, London

Acute Suppurate Otitis Media

Chronic Suppurative Otitis Media

Otitis Media with Effusion / Secretory Otitis Media

Adhesive Otitis Media

+/- Cholesteatoma

COMMON

NOT INFECTIVE

SELF LIMITING

Caused by ETD

(Eustacian tube dysfunction)

Negative MEP

Effusion of fluid in Middle ear

No pain, no fever, not unwell

Deafness, poor development of speech, behaviour

Cons / Medical / Surgical

Watch & wait

Hearing Aid

Ventilation tube

Effective

Compliance

NO ANTIBIOTICS

Perforation of TM

Follows a slow to heal ASOM

May be active or inactive

Safe / Unsafe perforation

Mucosal or cholesteatoma

Similar principles to cholesteatoma

safe

unsafe

What is it?

Keritinising squamous epithelium in middle ear cleft

How?

Congenital (rare)

Aquired - primary (retraction)

- secondary (implantation)

Skin migrates from umbo outwards across TM and out along canal

Pars flaccida

( 2 layers )

Pars tensa

( 3 layers)

Eustacian tube

dysfunction

Negative MEP

Retraction of pars

flaccida

RP fills with

debris

Infection

Erosion and

spread

Cholesteatoma

Same as ASOM + mastoiditis

But more insidious

Slow erosion more common

Conservative / medical / surgical

Conservative - microsuction, review

Medical – antibiotic drops

Surgical – cortical mastoidectomy

mastoidectomy

Conductive vs Sensorineural

Purple/green vs blue areas

Differentiate by tuning fork tests and tympanograms and Audiogram

Setup/physics

AC

BC

Masking

Sound has 2 components:

Frequency (pitch) cf. wavelength

Hz / kHz

Intensity (loudness) cf. amplitude

dB

Setup/physics

The cochlear does not hear all sounds equally at all frequencies

So, why does a normal PTA look like this?

Bone conduction

Used to prevent non-test ear hearing stimulus presented to test ear

Tympanometry

Measure of compliance of TM at varying pressures in EAM

Peak at 0dPa

Best movement of drum when no extra pressure on either side of TM

Peak at 0dPa, but unusually high

amplitude

? Ossicular disruption

Peak at 0dPa, but unusually low

amplitude

? Stapes fixation

No Peak

No best TM movement at any pressure

When tymp is flat,

usually means 1 of 3 things:

1. Artefact

2. Fluid in ME

3. Perforation

Look at EAM vol.

If large = perf

If normal = fluid

Peak at < 0dPa

Best movement of drum when no negative pressure in EAM thus middle ear pressure must be < atmospheric

Filtration (hairs/mucus/cilia)

Warming (30C)

Humidification

Olfaction

Vocal resonance

Bony upper 1/3

Cartilage lower 2/3 Alar

L Lat

U Lat

Septum

Turbinates (x3)

Ciliated epithelium

Sinus drainage to around middle turbinate

Anterior drain to middle meatus

Frontal

Maxillary

Ant Eth

Posterior drain superior meatus/sphenoethmoidal recess

Post Eth

Sphenoidal

Simple acute infective (=a cold)

Allergic (Mast cell degranulation): seasonal (pollen & spores) or perennial (dust mite, animal dander)

Treat with nasal steroids/antihistamines/ allergen avoidance

Intrinsic (10-15% population)

Obstruction

Vasodilatation

Oedema

sneezing

Imbalance of ANS supply to mucosa

PNS overrides SNS

watery rhinorrhoea

Medicamentosa

OTC decongestants are usually designed for short term use

Like heroin

Very difficult vicious circle to break free from

Inflammatory origin most common

neoplastic

CF

idiopathic

Aspirin/Asthma/Obstruction

Hx Ex Ix

Steroids/Surgery

Recurrence

Inflammation of the MM lining the paranasal sinuses

May be in conjunction with CAUSATIVE FACTOR

Medical Rx resolves most:

Analgesia

Decongestants

Steam

Antibiotics

Surgical Rx includes sinus washout

Retained secretions

blocked nose

frequent acute episodes

sinofacial pain

Take careful pain history before diagnosis

Visualise drainage system by CT

FESS

High incidence in those of Eastern origin

Hong Kong boat people (male)

Associated with:

Dried, salted, smoked fish

EBV

Genetic

Radiotherapy

Little place for surgery (not curative)

Very extensive anastamoses

Int Carotid & Ext Carotid branches

Ethmoidal arteries above MT

Sphenopalatine/Palatine/Labial below MT

Little’s Area

Kiesselbach’s plexus

Emergency talk

Congenital/Acquired

Deviated septum

Rhinitis

Polyps

Foreign body

Neoplasia

Collection of lymphoid tissue

Atrophies from age 6 to 12

If enlarged cause -nasal obstruction -Glue ear & recurrent

acute otitis externa -Snoring & sleep apnoea Adenoidectomy

curative

Aetiology: bacterial (Grp A Strep, Pneumococcus, Haemophilus); viral

Complications: Quinsy (peritonsilar abcess)

Treatment: penicillin

If multiple episodes (eg 6/yr) consider tonsillectomy

Swallowing: complex process.

Incidence: high in certain populations

Eg elderly , CVA, GORD

Associated with many different conditions.

Huge impact on QOL.

Important with relation to nutritional state.

May indicate sinister pathology.

Oral Preparatory

Oral

Pharyngeal

Oesophageal Duration & characteristics

of each phase depends on consistency and volume of food/drink taken.

Great majority= Squamous

Risk factors: smoking, alcohol

Location: majority on vocal folds

Presentation: hoarseness(followed by cough, irritation, referred otalgia, neck node)

Treatment: endoscopic removal, radiotherapy, laryngectomy

Lymphadenopathy

Thyroid/Parathyroid gland

Salivary Gland (parotid, submandibular…)

Thyro-glossal Cyst

Branchial Cyst

Carotid Body Tumour

Cystic Hygromata

Pharyngeal Pouch

Sterno-mastoid Tumour

Cervical Rib

NEOPLASTIC INFLAMMATORY

INFECTIVE

(TB/Syphilis)

ACUTE

Viral, Bacterial,

Fungal..

CHRONIC

NON-

INFECTIVE

(Sarcoid/

Rheumatoid)

BENIGN

MALIGNANT

PRIMARY

(Lymphoma

Sarcoma..)

SECONDARY

H&N and

visceral cancer

Patient age

Paediatric (0 – 15 years): 90% benign

Young adult (16 – 40 years): similar to paediatric

Late adult (>40 years): 12-20% malignant

Location

Congenital masses: consistent in location

Metastatic masses: key to primary lesion

Any solid asymmetric mass MUST be considered a metastatic neoplastic lesion until proven otherwise

Asymptomatic cervical mass – 12% risk of cancer

~ 80% of these are SCC

Ultrasonography

which can be used for Fine needle aspiration (FNAC)

Computed tomography (CT)

Magnetic resonance imaging (MRI)

Most common congenital

neck mass

50% present < 20yrs

Midline (75%) or near

midline (25%)

Inferior to hyoid bone

(65%)

Elevates c protrusion of

tongue

Surgical removal

(Sistrunk)

Anterior border of

sternocleidomastoid

2nd-3rd decade

following URTI

PAROTID SWELLINGS:

INFECTIONS: mumps, bacteria

TUMOURS:

80% of all salivary gland tumours arise in parotid

80% of parotid tumours benign

Whereas 80% of other salivary tumours malignant

Parotidectomy and Malignant parotid tumours can cause VIIth palsy

From old…

References in Egyptian hieroglyphics refer

to its use 3500 BCE

Chevalier Jackson in the early 20th century

popularised its use in the mainstream

Elective

Most common + most fun

Horizontal incision

Emergency

Less common but more ‘exciting’

Vertical incision

Airway obstruction

eg. Tumour, bilateral vocal cord palsy

Ventilation

long term intubation

Dead space and secretions weaning from ventilator, chronic lung disease

Protection of airway eg. Chronic aspiration

Cuffed and uncuffed

Fenestrated and unfenestrated

Single and double lumen

Various diameters

To protect airway

To allow ventilation

Uncuffed Cuffed

Allow patient to ventilate past tube via upper airway

Allow speech

Double lumen allows easy cleaning

Single lumen has a greater internal diameter

Skin

Dissection

Separate straps

Divide thyroid isthmus

Window in trachea

Below 1st ring

Stitch in place Incision=ba

d

Hole=good