Chapter 2 Ear, nose and throat and head and neck problems
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
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.
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
Hypopharynx
The hypopharynx and larynx are examined with a large mirror and head light as is the tongue base. Laryngeal assessment includes the epiglottis, vallecula, aryepiglottic fold, arytenoids, false cords, laryngeal ventricles, true cords, the subglottis and trachea. Reflux can often be detected by visualising reddening of the posterior glottis and arytenoids.
Head and neck lumps
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.
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.
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 |
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 |
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.
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).
Infective: may involve bacterial, viral, fungal and parasitic problems
Tumour: subdivided into benign and malignant
Metabolic causes such as diabetes and renal impairment
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.
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).
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.
External ear
Wax and otitis externa
Predisposing factors include the following.
The build-up of debris is subsequently infected by bacteria or fungi.
The most common bacteria is Pseudomonas aeruginosa. Fungal hyphae are seen in fungal infections.
Management
OE is best managed with one or more of the following measures:
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.
Complications of AOM are those resulting from mastoiditis and include:
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.
Inner ear
Hearing loss
There are many causes of hearing loss, as indicated in Table 2.5.
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
A complete examination with tuning fork tests is required and an audiogram will guide the diagnosis (Figs 2.8a and b).
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).
The most common causes of vertigo are:
Tinnitus
Defined loosely as noise generated somewhere in the head, tinnitus (Fig 2.10) is annoying to the patient and can be extremely disabling.
There are many causes for tinnitus, but the most common is idiopathic.
Reversible causes, such as outer, middle or inner ear pathology, need to be ruled out. An audiogram is a good screening test. CT and MRI may be ordered.
2.3 Facial weakness
Table 2.6 lists the most common 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
Management
Trauma
There are many forms of trauma. Trauma to the ear may result in:
2.4 Nose and sinuses
Anatomy/physiology
The nose and sinuses are made up of a number of components (Figs 2.11 and 2.12).
Nerve supply
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.
Treating epistaxis is based on the following principles.
Nasal obstruction
Pathological factors may include:
Sinusitis/nasal polyps/allergy
Complications of sinusitis include:
The following points are also worth noting.