Ear, nose and throat and head and neck problems

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Chapter 2 Ear, nose and throat and head and neck problems

Sarin Wongprasartsuk, Andrew Danks, Neil Vallance

2.1 Introduction

The specialty of ear, nose and throat — head and neck (ENT — head and neck) surgery is very broad and complex. Each component is a subspecialty in itself. Addressing any problems relating to the head and neck with this in mind will allow you to systematically approach the patient’s problem. As in any aspect of clinical medicine, the initial diagnosis is made by taking a thorough history prior to a complete physical examination that is supplemented by special investigations.

History

The common symptoms in the ear are otalgia, hearing loss, vertigo, tinnitus, aural fullness, discharge, hissing, facial weakness, bleeding and blockage. Common symptoms relating to the nose and sinuses are epistaxis (bleeding nose), nasal obstruction, hyposmia (decreased smell)/anosmia (complete loss of smell), loss of taste, facial pain, post-nasal drip, facial asymmetry, diplopia (double vision), epiphora (abnormal tears due to a blocked collecting system), redness of the eye, nasal discharge, allergy, sneezing and hay fever. Common symptoms relating to the throat include pain, dysphagia (difficulty swallowing), dysphonia (abnormal voice production), reflux, referred pain, cough, haemoptysis, shortness of breath, snoring and drooling. Head and neck patients may also present with symptoms of lumps and pain.

When a patient presents with any of these symptoms (Table 2.1) it is important to characterise the symptoms in terms of site, severity, radiation, frequency, duration, exacerbating and relieving factors, associated features, the progression of symptoms and how it affects the patient’s activities of daily living. When taking a history, the past history needs to be noted, including previous surgery to the respective parts of the ear, nose and throat, head and neck and any associated conditions. A patient’s medication and adverse reactions to medication should be known, as well as their social history, including their smoking and alcohol consumption and environmental exposures such as noise, dust and any other potential allergens. The family history should be known and it is also wise to find out about any family tendencies regarding bleeding disorders and deafness.

Table 2.1 Symptoms of ear, nose and throat conditions

Ear Otalgia, hearing loss, vertigo, tinnitus, aural fullness, discharge, hissing, facial weakness, bleeding, blockage
Nose and sinuses Epistaxis, obstruction, hyposmia/anosmia, loss of taste, facial pain, post-nasal drip, facial asymmetry, diplopia, epiphora, red eye, nasal discharge, allergy/sneezing/hay fever
Throat Pain, dysphagia, dysphonia, reflux, globus, referred pain, cough, haemoptysis, shortness of breath, snoring, drooling
Head and neck: lump, pain

Examination of the head and neck

As stated, a systematic approach to examining the head should recognise the principles of ENT — head and neck and include this in the examination, along with the cranial nerves. This will make a complete examination of the area. It is important to be aware of referred pain (Fig 2.1); for example, the ear is supplied by multiple nerves and ear pain can present as referred pain from intraoral or laryngeal pathology. Look for signs of redness, swelling, tenderness, increased warmth and loss of function.

Throat

When examining the throat, examine the mouth, the pharynx (which is subdivided into the nasopharynx, oropharynx and the hypopharynx), the tongue base and the larynx.

Head and neck lumps

When a lump is assessed, remember the mnemonic ‘Surgeons Can Find The Lumps’: Each lump should be characterised according to:

Site, size, surface, sinus

Colour, contour, cough, compressibility

Fluctuance, fixation, fluid, filling and emptying

Temperature, transillumination, thrill, tenderness

Local features, lobulation, lymph nodes, lumps elsewhere.

Palpation of the head and neck involves palpation of the lymph nodes and the thyroid gland. It is important to palpate one side of the head and neck at a time and systematically approach all the groups of lymph nodes (Fig 2.2). Deep palpation of the jugular chain is important because these glands are deep to sternocleidomastoid. One should take care when compressing around the carotid.

The lymph node groups are divided into groups commonly known as 1–6. There is a seventh group but it is often not included. The groups are:

The other areas that need to be palpated are the parotid, the posterior occipital nodes and the post-auricular region.

The lymph node groups drain specific areas of the head and neck, which in turn relates to the treatment of various head and neck cancers.

Table 2.2 outlines the process for performing a thyroid examination when thyroid disease is detected or suspected. Table 2.3 outlines an examination of the cranial nerves.

Table 2.2 Thyroid examination — performed if thyroid disease is detected or suspected

Look Patient — hyper/hypothyroid, thyroid eye signs, proptosis — Graves’ disease, lid lag, chemosis a complication, voice — recurrent laryngeal nerve compression, goitre
Feel Right versus left side, prominent nodules
Percuss — retrosternal extension
Auscultate — bruits
Pemberton’s sign — a sign of SVC compression — raise arms above head and look for venous congestion in the head
Periphery Pulse, reflexes

Table 2.3 Screening examination of the cranial nerves

I Smell
II Visual acuity, light reflex — direct and consensual, fields
III/IV/VI Eye movements
V — V1, V2, V3 Sensation, motor — palpate jaw (masseter, temporalis)
VII Facial movements: temporal — forehead; zygomatic — eye closure; buccal — cheek; marginal mandibular — lower lip; cervical — platysma
VIII Tuning fork
IX/X Gag reflex
XI Sternocleidomastoid, trapezius — palpate
XII Tongue mobility; palsy indicated by protrusion to affected side

A gait examination is often performed as part of the dizziness assessment and is covered in the neurologic examination.

The voroscope (Fig 2.3) has revolutionised the ENT — head and neck examination. A good headlight from theatre will often suffice. Sometimes only a light source and head mirror are available.

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Figure 2.3 Voroscope

Photos courtesy of Mr Sarin Wongprasartsuk

Flexible nasal endoscopy has also revolutionised the diagnosis of ENT — head and neck conditions. It has become an integral part of the examination and enabled office-based diagnosis. There are many hidden areas in ENT — head and neck examination and the nasoendoscope has permitted access to the internal nose, sinus outflow tracts, post-nasal space, larynx, hypopharynx, tongue base and sometimes the proximal oesophagus (Fig 2.4).

image

Figure 2.4 Nasolaryngoscope

From Dhillon & East, 2006

After the thorough history and complete physical examination have been performed, investigations are ordered. A differential diagnosis should be considered and the mnemonic VITAMIN CID may be helpful.

Vascular

Infective: may involve bacterial, viral, fungal and parasitic problems

Tumour: subdivided into benign and malignant

Accident

Metabolic causes such as diabetes and renal impairment

Immune/autoimmune conditions

Nutritional causes

Congenital

Idiopathic

Drugs and alcohol

Investigations are ordered to:

The common investigations include:

The last four investigations are usually ordered by ENT — head and neck specialists.

2.2 Ear

The ear has three components consisting of a number of parts listed in Table 2.4.

Table 2.4 Outer ear, middle ear and inner ear components

Outer ear Pinna — parts
External auditory canal — lined by skin, acts to remove accumulated squames from the tympanic membrane out of canal
Tympanic membrane
Middle ear Ossicles: malleus (hammer)/incus (anvil)/stapes (stirrup) — act as the chain between the tympanic membrane and the oval window membrane
Eustachian tube — functions to aerate middle ear
Middle ear mucosa — respiratory type
Mastoid cells — part of the temporal bone and joined to middle ear cleft
Inner ear Cochlea and vestibular apparatus
Oval window — superior — part of the cochlear connection to ossicular chain
Round window — inferior — part of the cochlea that moves in response to any hydraulic force placed on the oval window

To examine an ear, systematically investigate the outer ear followed by the middle ear and then the inner ear (Fig 2.5).

image

Figure 2.5 Anatomy of the ear

From Dhillon & East, 2006

For the outer ear look at the normal contour of the outer ear, the ear canal and the tympanic membrane. Sometimes it is necessary to remove the wax from the canal to get a good view. When assessing the middle ear also assess for tympanic membrane mobility using what is called pneumatic otoscopy. Check any perforation of the tympanic membrane by assessing its size, the site, associated discharge and the condition of the middle ear mucosa. The tests of the inner ear that are commonly performed are: using a 512 Hz tuning fork; testing a patient’s gait; and performing a Dix-Hallpike manoeuvre. Prior to performing a Dix-Hallpike manoeuvre the stethoscope should be used to listen for any carotid bruits because the Dix-Hallpike manoeuvre may precipitate a TIA. The stethoscope is also used to listen for pulsatile tinnitus and is placed on the mastoid tip. The Dix-Hallpike manoeuvre is diagnostic of benign paroxysmal positional vertigo (BPPV) and is performed on an examination couch. While sitting up, the patient turns their head quickly to one side while keeping the eyes wide open and focusing on a spot in the distance in the line of their eye sockets. Next, the patient lies back with their head dependent over the head of the examination bench. The examiner inspects for nystagmus, which indicates an overstimulated semicircular canal system. It is a positive result when nystagmus is elicited on the side to which the head is turned.

Facial nerve (CN VII). This nerve courses through the temporal bone then enters the internal auditory canal in the antero-superior quadrant. It then passes forwards in what is called the labyrinthine segment and passes above the cochlea, contributing to the geniculate ganglion that has branches to the petrosal nerves. It then turns back and runs between the lateral semicircular canal superiorly and the oval window that is attached to the stapes, inferiorly. After passing these two structures it courses down in the stylomastoid canal giving off two branches: first, the nerve to the stapedius and then the chorda tympani that relays taste sensation from the anterior two-thirds of the tongue. The facial nerve exits the skull base via the stylomastoid foramen. It is termed the trunk of the facial nerve at this point. It gives off its auricular branch and then separates into a superior and inferior division. The superior division has temporal, zygomatic and buccal branches and the inferior division has the marginal mandibular and the cervical branches. These braches supply the muscles of facial expression.

Vestibulocochlear nerve (CN VIII). The cochlear nerve occupies the antero-inferior quadrant of the internal auditory canal (IAC). The superior division of the vestibular nerve occupies the postero-superior quadrant of the IAC and the inferior division of the vestibular nerve occupies the postero-inferior quadrant. The cochlear nerve conducts sound and the vestibular nerve conducts the sensation of balance.

External ear

Middle ear

Otitis media

Otitis media is an inflammation of the middle ear/mastoid cavity. Its underlying cause is an abnormality of the Eustachian tube that ceases to aerate the middle ear, leading to a range of possible complications (Figs 2.6 and 2.7). A negative pressure forms in the cleft and an effusion results. There are many causes of a dysfunctional Eustachian tube. In children, the Eustachian tube is shorter and more horizontal, therefore, more prone to blocking. Causes include: viral URTI, cleft palate and a post-nasal space tumour. The effusion may become secondarily infected resulting in acute otitis media (AOM). Common organisms are: Streptococcus pneumoniae, Haemophilus influenzae and Moraxella.

AOM presents with otalgia, fever and a red, inflamed ear drum. The treatment may include antibiotics and antipyretic analgesia. The tympanic membrane may spontaneously rupture, resulting in a discharging ear and immediate pain relief.

Otitis media with effusion (OME) presents with a conductive hearing loss and a dull ear drum. Most cases of OME in children (about 90%) will resolve within three months, as there is often a preceding URTI. In adults, a new onset effusion with no precedent URTI needs to be investigated. The post-nasal space needs to be visualised. In longstanding effusions, a middle ear ventilation tube (grommet) is inserted to resolve the effusion.

Complications of AOM are those resulting from mastoiditis and include:

CT scan findings consistent with mastoiditis are opacification of the middle ear/mastoid cleft associated with bony destruction of the normal bony trabeculae.

A chronic discharging ear for more than three months is termed chronic suppurative otitis media (CSOM). It results from chronic infection, with an associated biofilm formation or may be caused by a cholesteatoma.

A cholesteatoma is a sac of keratinised squamous epithelium that has the potential to grow and erode the surrounding structures resulting in hearing loss, discharge and potential intracranial complications.

A bacterial biofilm is a colony of bacteria that has formed a resistant matrix often on an inert surface. Bacterial biofilms result in chronic infections in the ear, nose and throat.

Inner ear

Hearing loss

There are many causes of hearing loss, as indicated in Table 2.5.

Table 2.5 Causes of hearing loss

Cause Conductive hearing loss Sensorineural hearing loss
Congenital Atresia of ear, ossicular abnormalities Prenatal: genetic, rubella
Acquired External: wax, otitis externa, foreign body Perinatal: hypoxia, jaundice
  Middle ear: middle ear effusion, chronic suppurative otitis media, cholesteatoma, Trauma: noise, head injury, surgery
  Perforated drum, otosclerosis, traumatic perforation of drum Inflammatory: chronic otitis, meningitis, measles, mumps, syphilis
  Ossicular disruption Degenerative: presbyacusis
    Ototoxicity: aminoglycosides, cytotoxics
    Neoplastic: acoustic neuroma
    Idiopathic: Ménière’s disease, sudden deafness

Based on Dhillon & East 2006

When evaluating hearing loss, the outer ear, middle ear, inner ear and central pathways need to be considered. The time frame, whether sudden or acute versus chronic, needs to be ascertained. A prior history of trauma, noise exposure and associated symptoms is a valuable clue.

A complete examination with tuning fork tests is required and an audiogram will guide the diagnosis (Figs 2.8a and b).

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Figure 2.8a Tuning fork tests

From Dhillon & East, 2006

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Figure 2.8b Audiograms

From Dhillon & East, 2006

CT, MRI and other auditory tests such as stapedial reflexes (a test of middle ear function/fixation of the stapes in otosclerosis), otoacoustic emissions (a test for cochlear function) and auditory brain stem responses (ABR) (a test of the central pathway) will assist with localisation of the problem.

Vertigo

Vertigo can be disabling. The vestibular apparatus may be overactive or underactive. An imbalance between the left and right sides may result in vertigo. There are many causes (Fig 2.9).

image

Figure 2.9 Otologic causes of dizziness

From Dhillon & East, 2006

The most common causes of vertigo are:

When assessing a patient with a balance problem, the components of balance disorders that need to be addressed are the cardiovascular system (CVS), central nervous system (CNS)/peripheral nervous system (PNS), cerebellum, vestibular system and vision. Often the causes are irreversible and may progress. The ongoing therapy involves physiotherapy and occupational therapy to make sure it is safe for a patient to return home.

Vestibular function testing may be of assistance in diagnosing the probable cause, as is imaging. MRI is used to assess the brain, brainstem and retrocochlear region, whereas CT is used to assess the middle ear anatomy.

2.3 Facial weakness

When a patient presents with a facial weakness a systematic approach needs to be adopted, considering the components and course of the facial nerve together with the VITAMIN CID mnemonic. Consider:

Table 2.6 lists the most common causes of facial weakness.

Table 2.6 Causes of facial weakness

Site Aetiology
Intracranial Acoustic neuroma
  CVA*
  Brain stem tumour*
Intratemporal Bell’s palsy
  Herpes zoster oticus
  Middle ear infection
  Trauma
  – surgical
  – temporal bone fracture
Extratemporal Parotid tumours
Miscellaneous Sarcoidosis, polyneuritis

Based on Dhillon & East, 2006

* Supranuclear lesions.

2.4 Nose and sinuses

Epistaxis

Most commonly epistaxis is anterior and unilateral (approximately 90%) from Little’s area. Posterior epistaxis is uncommon; it presents bilaterally and is often severe from the sphenopalatine artery.

Contributing factors include:

Treating epistaxis is based on the following principles.

Nasal obstruction

Often when we refer to the nose we actually mean the nose and paranasal sinuses. Patients will often present with the complaint of a blocked nose and pain around the area of their sinuses. Associated symptoms include hyposmia, anosmia and loss of taste. More sinister symptoms might be facial sensory loss — V1 or V2, or diplopia.

The cause of nasal obstruction can relate to anatomical, mucosal and pathologic factors. Remember the nasal airway extends from the skin of the nostril to the post-nasal space.

Anatomical factors include deviated nasal septum, nasal bones, anatomical variants of the normal sinus outflow tracts and adenoid hypertrophy.

Mucosal factors include turbinate mucosal hypertrophy. The turbinates have a blood and nerve supply and the epithelium is respiratory with glandular elements. Therefore, they shrink and enlarge in response to conditions that affect:

Pathological factors may include:

Beware of new onset unilateral nasal hypertrophy in adults — you must rule out a tumour. There are certain conditions to watch out for: