	Rinne	Weber
Normal	Air conduction better than bone conduction (test positive)	Both sides equal
Conductive deafness	Bone conduction better than air conduction (test negative)	Heard loudest on the affected side
Sensorineural deafness	Air conduction better than bone conduction but both reduced compared to normal (test positive but reduced)	Heard loudest on the good side

Pure tone audiometry and impedance audiometry, along with electric response audiometry, further refine the investigations (Fig. 21.2).

Figure 21.2 An audiogram. (a) Sensorineural loss with reduced hearing levels by both air and bone conduction. (b) Conductive hearing loss with reduced hearing level by air conduction and normal bone conduction.

Diseases of the external ear

Foreign bodies

Skilled personnel should always do extraction of foreign bodies to reduce the danger of forcing the foreign body further into the ear where it may damage the drum and middle ear.

Trauma to the auricle

Haematoma may occur, particularly in boxers and those who take part in contact sports. If blood extravasates between the cartilage and perichondrium, a cauliflower deformity composed of fibrous tissue ensues (classically seen in rugby forwards who damage ears in scrummages).

Otitis externa

Clinical features

There is discharge from the ear and occasional mild pain. In the spreading, necrotising variant, there is systemic disturbance with severe local symptoms which may include the development of a seventh nerve palsy.

Management

In the mild type, topical antiseptics and antibiotics are incorporated into eardrops containing steroids. Aural toilet is essential, best done by an ENT surgeon with a microscope and micro-suction equipment. In severe cases, therapy consists of intensive local treatment with excision of dead tissue and administration of systemic antibiotics.

Diseases of the middle ear

Diseases of the inner ear

Sensorineural hearing loss

Causes include:

• genetic abnormalities

• maternal infections during pregnancy, for example rubella, cytomegalovirus and syphilis

• perinatal hypoxia

• viral and bacterial labyrinthitis

• meningitis

• ototoxic drugs, for example gentamicin, neomycin

• noise-induced hearing loss

• fractures of the temporal bone

• barotrauma to include rupture of the round window.

High audiometric frequencies are usually affected first. Tinnitus is often associated with sensorineural loss. Exposure to high intensity noise causes characteristic bilateral hearing loss on the audiogram.

Management includes hearing aids and air conduction aids consisting of miniature microphone, amplifiers and receivers. Bone conduction aids are used if there is a congenital absence of the pinna and atresia of the canal. Those who do not benefit from hearing aids may benefit from a cochlear implant.

Acoustic neuroma

Clinical features

There is unilateral or marked asymmetric sensorineural hearing loss and tinnitus. The audiogram reveals unilateral sensorineural hearing loss. MRI scan demonstrates the tumour.

Management

The tumour is removed by neurosurgery, hopefully with minimal damage to the facial nerve.

Menière’s disease

Distension of the membranous labyrinth caused by endolymphatic hydrops is thought to be the pathological feature of Menière’s disease. A characteristic triad of symptoms comprises vertigo, fluctuating sensory loss and tinnitus. Hearing gradually deteriorates over a period of time. Attacks of vertigo are treated with vestibular sedatives, for example diazepam and prochlorperazine. A salt-restricted diet may reduce the frequency of attacks. Decompression of the endolymphatic sac and vestibular neurectomy is indicated if medical treatment fails.

The nose and paranasal sinuses

Features of nasal and sinus disease

Symptoms include nasal obstruction, mouth breathing, discharge and post-nasal drip. Unilateral discharge in a child probably originates from a foreign body. Bloodstained discharge with unilateral symptoms may be associated with tumour. Copious, watery discharge may suggest CSF rhinorrhoea. Facial pain may also occur, occasionally radiating into the teeth, eyes or ear. There may also be headaches, loss of smell, bleeding and cosmetic nasal deformity.

The anterior part of the nose can be examined using a nasal speculum. Deformities of the septum, mucosal changes, vessels and inferior and middle turbinates can be seen. Polyps, tumours, ulceration and foreign bodies can be identified. The posterior nasal space can be examined through the mouth by introducing a small mirror behind the soft palate.

Investigations of nasal disease:

• X-ray, which may show gross disease

• CT scanning of the sinuses gives precise images demonstrating mucosal swelling, fluid levels or opacities, as well as bony erosion by tumours

• MRI is especially useful for determining tumour infiltration

• Skin prick tests may identify possible allergens

• Smell may be detected by exposure to various bottles containing pungent substances, establishing whether smell is reduced or distorted.

Common conditions

Foreign bodies

Children often insert foreign bodies into the nostril, which may go undetected for some time. They may present with symptoms of unilateral discharge. A radio-opaque body may be seen on plain X-ray, which can then be removed with forceps, or hook; this may require a general anaesthetic.

Fractures of the nose

These may be associated with other fractures of the face, including zygoma, bony orbit and middle third. Symptoms include nasal deformity, obstruction and bleeding. Examination may demonstrate a deviated septum or haematoma. Nasal fractures may be reduced immediately or 7–10 days after the swelling has subsided.

Septal haematoma and abscess may develop between the mucoperichondrial flaps of the septum leading to septal cartilage ischaemia and secondary infection. This may lead to a saddle-type nasal deformity. The haematoma should be incised and drained. Nasal packing should be applied to allow the perichondrium to adhere to the cartilage.

The treatment of deviated nasal septum includes a septoplasty/submucus resection (SMR) where the cartilage is mobilised and the deviated part of the septum is excised.

Epistaxis

Several vessels anastomose in the anterior septum, known as Little’s area, a frequent site for anterior nasal bleeding. Causes include:

• trauma

• tumours

• infection with ulceration

• prominent vessels

• atherosclerotic degeneration of greater nasal arteries

• bleeding diatheses

• blood disease

• hereditary telangiectasia.

Management

The nose is anaesthetised and decongested with 10% cocaine. The bleeding vessel can be cauterised chemically. If the bleeding point cannot be identified, ribbon gauze impregnated in bismuth iodoform paraffin paste (BIPP) is packed into the anterior nasal cavity. When the bleeding is from the back of the nose, an epistaxis balloon may be introduced through the nose into the post-nasal space and is then drawn forward through the nose and secured. Packs remain for 48 hours. Antibiotics are given. Frequent, repeated haemorrhage may require ligation of the appropriate vessel (e.g. external carotid, maxillary artery, ethmoidal arteries). Modern developments have also allowed embolisation of bleeding vessels by interventional radiologists.

Rhinosinusitis

Mucosal changes in the sinuses are often accompanied by changes in the nasal cavities. The causes are allergy, idiopathic or infective. In allergic rhinitis, inhaled substances including pollens from grass, trees and flowers are responsible for seasonal symptoms. House dust and pet fur cause more perennial symptoms. Acute infective rhinitis occurring secondary to the common cold or viral infections may be complicated by secondary bacterial infection. Common organisms include Haemophilus influenzae and Streptococcus pneumoniae. Any condition that interferes with mucociliary transport, for example deviated septum, polyps or hypertrophy of the turbinates, may predispose to the development of infective sinusitis. Swollen mucosa blocks the natural ostia and pus reduces the activity of the cilia leading to stasis in the sinuses. In chronic infection, the mucosa may be damaged and granulations may develop.

Symptoms of allergic rhinitis include:

• nasal itching

• sneezing

• profuse, watery discharge

• post-nasal drip.

With infective rhinosinusitis, the symptoms are unilateral, including:

• pain over the affected sinus and around the eye

• headache

• mucopurulent discharge

• nasal obstruction

• loss of smell.

Sinus X-ray and CT scan may reveal opaque sinuses or a fluid level.

Management of allergic rhinitis depends on demonstration of the allergen and advice on how to avoid it. Prophylaxis using sodium cromoglicate and steroid sprays may be effective and is without adverse systemic effects. Occasionally, non-sedating oral histamines may be added. Infective rhinosinusitis is treated with antibiotics and decongestant drops. Surgery may be required to re-establish air flow, including sinus washout, intranasal antrostomy or radical antrostomy (Caldwell–Luc operation).

Complications of infective sinusitis include:

• periorbital cellulitis

• subperiosteal abscess

• blindness

• suppuration of orbital contents

• osteomyelitis

• complications of the frontal bone and maxilla with subsequent sinus formation

• intracranial complications including meningitis, brain abscess and cavernous sinus thrombosis.

Symptoms include:

• diplopia

• restricted eye movement

• reduction of visual acuity

• swollen eyelids proptosis.

Intracranial complications may include:

• headache

• drowsiness

• photophobia.

Cavernous sinus thrombosis occurs rarely and is characterised by proptosis, swelling of the eyelids and ophthalmoplegia. CT scan demonstrates the opaque sinuses, bony defect, abscess formation, displacement of the eye and brain abscess.

Nasal polyps

These are pale grey, pedunculated mucosal tissue masses projecting into the nasal cavity. They originate in the region of the ethmoid. Twenty-five per cent of cases are associated with asthma and possible aspirin sensitivity (8%). Nasal obstruction, loss of smell and sneezing are the common complaints. The lesions may be visible on endonasal examination. Medical management includes topical steroid sprays. In the majority of cases, surgical removal is required, although polyps may recur.

Tumours of the nasal cavity

Benign and malignant tumours in the nasal cavity are rare. Benign tumours include papilloma, which has a tendency to recur, and there is a small risk of malignant change. The tumour is removed using the lateral rhinotomy approach. Osteomas may be an accidental finding on sinus X-ray. They are more common in the frontal area. These may be removed by a fronto-ethmoidectomy. Malignant tumours are squamous cells in origin and present with nasal and eye symptoms. Tumours in the nasal cavity and ethmoids present with nasal and eye symptoms. Maxillary tumours present with dental, orbital and nasal symptoms with facial swelling. Often the first feature is a lymph node in the neck. Treatment is a combination of radiotherapy and surgery. Craniofacial resection may be required when there is an extension of the tumour into the anterior cranial fossa.

Swellings in the neck

Clinical features

Important features include:

• the duration of the swelling

• its size progression

• pain

• other symptoms including hoarseness and dysphagia

• weight loss

• night sweats

• history of chronic exposure to alcohol or tobacco.

On examination, the site and size along with the relationship to other anatomical structures and fixation of the lump including its pulsatility or the presence of a bruit or thrill, tenderness or fluctuation must be noted. A thorough examination of the oral cavity and oropharynx must be made. The nasopharynx and laryngopharynx require indirect examination with a mirror.

Sites of swelling in the neck (Fig. 21.3) may indicate their origin. The most important landmark is the sternocleidomastoid muscle, which divides the neck into anterior and posterior triangles.

• Parotid swellings occur in front of the tragus over the angle of the mandible or below the lobe of the ear. Facial palsy may suggest malignant involvement.

• Submandibular gland swellings may be palpated bimanually via the mouth. They are difficult to distinguish from regional lymphadenopathy.

• Midline submental swellings are commonly a thyroglossal cyst, midline dermal cyst or pyramidal lobe of the thyroid.

• High anterior triangle swellings may be metastatic from the oral cavity but may also include branchial cyst or carotid body tumour.

• Low anterior triangle swellings are related to the thyroid or metastases from primary tumours in the larynx or pharynx.

• Supraclavicular swellings are common on the left side of the neck, caused by disease below the level of the clavicle, for example carcinoma of the lung or stomach.

• Posterior triangle swellings are rarely metastatic but more commonly tuberculosis, toxoplasmosis and lymphoma.

Figure 21.3 Sites of swelling in the neck and their likely causes.

Lymph node enlargement is the commonest cause of a neck lump (see Fig. 21.3). Lymph nodes in the neck should not be biopsied until an ENT surgeon has excluded a primary tumour of the upper aerodigestive tract.

In most cases, multiple cervical masses are accompanied by an acute systemic illness or more chronically may be a presentation produced by tuberculosis. A swelling which is tender and has enlarged over a few days is almost always inflammatory. Lymphomas tend to develop over a period of weeks and are painless. Metastatic nodes may be tender on palpation but rarely cause pain unless there is invasion of surrounding nerves.

Investigation of neck lumps

Fine-needle aspiration (FNA), ultrasound and CT scanning are all useful to determine the cause. Blood tests may help diagnose infection causing lymphadenopathy (e.g. monospot test in glandular fever or HIV antibodies in HIV infection). If FNA suggests squamous carcinoma, an upper aerodigestive tract endoscopy must be done to include examination of the nasopharynx, hypopharynx, larynx and trachea, bronchus and cervical oesophagus. Adenocarcinoma metastases are usually of intra-abdominal or intrathoracic origin. If the cytology suggests lymphoma, incision biopsy may be necessary for further tissue to identify the lymphoma type. If a primary ENT tumour is found at endoscopy, treatment recommended depends on the site and size of the primary and cervical node metastases.

Specific causes of neck swellings

Lymphoma

The majority of lymphomas in the head and neck are non-Hodgkin’s in type. Fine-needle aspiration cytology is insufficient for diagnosis and excision biopsy is required. Even if lymphoma is suspected, a primary ENT tumour must be excluded before excision, since removal of a node which turns out to be a metastasis of a primary cancer of the upper aerodigestive tract may prejudice subsequent treatment. Treatment of lymphomas is by haematologists and oncologists rather than surgical.

Thyroglossal cyst

Presentation occurs during the second or third decade of life. The mass is midline, between the thyroid notch and hyoid bone and moves upwards on protrusion of the tongue. The cyst is removed surgically and the central portion of the hyoid bone may need to be included in the excision.

Branchial cyst

Presentation occurs between the ages of 15 and 35 with a cyst in the upper part of the anterior triangle. It is smooth and mobile. The diagnosis is confirmed by FNA, which produces pale, creamy fluid. Treatment is by excision.

Carotid body tumour (chemodectoma)

Ten per cent are familial, 10% are bilateral and 10% are malignant. The patient presents in adult life with a history of a lump which is ovoid, non-tender and pulsatile. There is mobility in the horizontal but not vertical axis. Auscultation reveals a bruit. CT scan confirms the lesion. Carotid angiography may demonstrate a highly vascular mass. Surgical excision is required, and this is more easily done before the tumour gets too large (>2 cm).

Tumours of the upper aerodigestive tract

Malignant tumours are more common than benign. Squamous cell carcinomas are the most common form followed by lymphomas, salivary gland tumours, melanomas and sarcomas.

Squamous carcinoma

The most important predisposing factors are smoking, high alcohol intake and the presence of pre-malignant conditions. Other factors include chronic irritation, betel nut (common in the Indian subcontinent) and oral syphilis (rare).

Clinical features of upper aerodigestive tract tumours are site specific and may include local problems, for example unilateral nasal obstruction and epistaxis, diplopia, middle ear effusion or loosening of teeth. Local pain and referred otalgia are common. Many lesions are asymptomatic and the presenting symptom is a lump in the neck due to a lymph node metastasis. Hoarseness of the voice occurs in advanced cases. There may also be dysphagia in laryngeal, hypopharyngeal and cervical oesophageal lesions. Investigation depends on the known or likely site of the tumour. The presence of an unexplained hoarse voice for more than 6 weeks is an indication for direct laryngoscopy and biopsy. A diagnosis of functional dysphagia should not be made until both a barium swallow and oesophagoscopy have been shown to be normal.

Treatment

A multidisciplinary approach is required, using a combination of surgery and radiotherapy. Eradication of the tumour is a priority but preservation of function, particularly speech and swallowing, is important. Many patients present with advanced tumours and supportive care and analgesia are appropriate. For small tumours (stage T1 and T2), a full course of radiotherapy is the treatment of choice. Recurrences need to be treated by surgery. Large tumours do not respond well to radiotherapy and primary surgery is offered with or without postoperative radiotherapy. The metastatic lymph nodes may be treated at the same time as the primary tumour, either by radiotherapy or surgery. Some primary sites, for example tongue, bone and tonsil, have a high risk of microscopic nodal disease and prophylactic treatment of the ipsilateral neck is undertaken.

Survival rates depend on the size and site of the primary tumour and the presence or absence of metastatic disease. If lymph node metastases have developed, the prognosis for any tumour worsens considerably. The overall 5-year survival rate for all head and neck malignancies is 40%. Reconstruction of the defect after surgery for a large tumour is difficult to achieve and requires plastic surgical techniques including free grafts of split or full thickness, pedicled skin flaps or free flaps with varying results. Restoration of speech is possible by creating a tracheal-oesophageal fistula where a one-way valve is introduced. By occluding the tracheostomy with a finger during exhalation, the patient can divert air through the valve into the pharynx, thus producing speech by the air being set in vibration by the valve.

Diseases of the salivary glands

The three paired salivary glands (the parotid, submandibular and sublingual glands) may be subjected to viral and bacterial infections and neoplasia.

Parotitis

Infection in the parotid or submandibular salivary glands is uncommon but tends to occur in elderly, debilitated patients. In parotitis, the gland swells and becomes acutely tender. A plain X-ray may demonstrate a stone in the duct, which can also occur in the submandibular duct with similar clinical features and the stone identified on X-ray. Parotitis requires excellent mouth care, rehydration and antibiotics. Submandibular sialadenitis is treated in the same way but, if a stone is obvious, excision of the duct and removal of the stone may be required. Care must be taken when removing the duct that damage is not caused to the lingual nerve.

Pleomorphic adenoma

This is the most common benign tumour. If left for many years, it may undergo malignant transformation. The history is of a painless mass, usually in the parotid, which enlarges very slowly over a period of years. Surgical excision is the treatment of choice but requires careful removal to avoid rupture of the capsule (which may lead to tumour seeding and recurrence). A superficial parotidectomy is performed, avoiding injury to the facial nerve. Adenolymphoma (Warthin’s tumour) is another common benign tumour of the parotid gland but may occur bilaterally in 10% of cases. Malignant neoplasms of the salivary glands are rare. Mucoepidermoid carcinomas, squamous carcinomas, adenocarcinomas and adenoid cystic carcinomas are the usual histological types. Surgery is the mainstay of removal. If a malignant parotid tumour directly involves the facial nerve, this structure must be sacrificed and continuity re-established using a segment of greater auricular or sural nerve.

Infection of the neck space

Peritonsillar abscess (quinsy)

There is a background history of acute tonsillitis which suddenly progresses with unilateral pain and dysphagia. A fluctuating pyrexia is invariable with the tonsil being displaced downwards and medially on examination. Intravenous antibiotics may be given in the early stages but, if there is a suspicion of pus, the inflammatory mass is incised.

Parapharyngeal abscesses, occurring lateral to the pharyngeal constrictors containing the carotid tree, internal jugular vein and cranial nerves, usually occur as a consequence of dental sepsis. Complications include direct spread to the mediastinum or mucosal oedema and pharyngeal and airway obstruction. Treatment is essential with intravenous antibiotics. A CT scan is obtained to ascertain whether or not there is a collection of pus. If present, this is drained through an incision running down the anterior border of the sternomastoid muscle.

Ludwig’s angina

This is a soft tissue infection of the floor of the mouth on both sides of the mylohyoid muscle, usually resulting from dental sepsis. There is gross oedema of the mucosa of the floor of the mouth with upward and posterior displacement of the tongue which may obstruct the airway. Initial treatment with antibiotics and drainage of pus is the treatment of choice but it may be necessary to maintain the airway by nasopharyngeal-tracheal intubation or tracheostomy.

Vocal cord paralysis

This is the consequence of damage to the ipsilateral recurrent laryngeal nerve. Common causes include thyroid surgery, cardiac surgery, carcinoma of the bronchus, thyroid or oesophagus. Diagnosis depends on a detailed search for the cause. Treatment should only be undertaken for those patients who have an identifiable non-reversible cause. Medialisation of the vocal cord is used when one cord is paralysed, which is then moved medially to improve the voice and reduce aspiration, either by the injection of Teflon paste or a piece of thyroid cartilage wedged between it and the thyroid ala. Lateralisation of the vocal cord is used to improve the airway in bilateral palsy. In bilateral paralysis, permanent tracheostomy is usually the best management.

Tonsillectomy

The indications for tonsillectomy are given in Box 21.3.

Box 21.3 Indications for tonsillectomy

Recurrent tonsillitis with more than four attacks per year

Obstructive sleep apnoea with tonsillar hypertrophy in children

Peritonsillar abscess with a past history of recurrent tonsillitis

Persistent sore throat after glandular fever

Unilaterally enlarged tonsil with lymphoma a possibility

The two types of open tracheostomy are shown in Figure 21.4, either after a laryngectomy where the divided trachea is brought out and sutured to the skin or more frequently where a side opening is made and a tracheostomy tube is inserted on a temporary, permanent, elective or emergency basis. The indications for tracheostomy are given in Box 21.4. Temporary tracheostomy can be achieved percutaneously and is gaining popularity on intensive care units as it avoids the need for specialist ENT input and can be done at the bedside.