Is parotid serous or mucinous?
which gets more salivary stones (calculi) and why? give 2 reasons
submandibular gland does because it has mucinous secretions and the gland lies below the OPENING of the duct therefore impeding drainage and encouraging stasis
which muscle does parotid duct pass forward over and which does it pierce?
anteriorly over masseter and pierces buccinator
which muscle acts as a sphincter to the parotid duct and what important role does it play?
buccinator muscle acts as a sphinter. its prevents reflux of air and therefore air insufflation when intra oral pressure is increased eg when playing trumpet
where does parotid duct open?
on the mucous membrane of the cheek, opposite the 2nd UPPER MOLAR TOOTH
how many lobes does the parotid gland have?
2 lobes superficial and deep (+/- accessory lobe). so important to look inside mouth for deep lobe
in mumps parotitis why do you pain in the parotid gland?
parotid gland is surrounded by tough fascial fibrous capsule made from investing layer of deep cervical fascia. this gets acutely swollen in mumps
which structures lie in the parotid gland going from superficial to deep?
- 5 terminal branches of facial nerve (two zebras bit my cat) (Temporal Zygomatic Buccal Mandibular Cervical)
- retromandibular vein
- external carotid artery
during parotid surgery what structures are easily damaged, how do you know youve damaged them?
branches (TZBMC) of facial nerve. once u see retromandibular vein its too late as that is deep to nerve!
what disease of parotid gland can cause facial paralysis?
malignant tumour of parotid gland which is highly invasive and quickly involves facial nerve.
what is the secretomotor supply to the parotid gland?
- parasympathetic fibres of glossopharyngeal nerve
- synapse in otic ganglion
- go towards parotid gland
- through auriculotemporal nerve
after injury to the parotid gland either from surgery or penetrating trauma, what is a potential complication and what does it involve? what change will the pt experience?
- frey's syndrome. after injury - get reinnervation of auriculotemporal nerve fibres to sweat glands in the skin of the face.
- causes GUSTATORY SWEATING. ie when youre about to eat - stimulus for saliva production but instead get sweating!
what causes otosclerosis?
- fixation of stapes footplate at oval window causing conductive hearing loss
- presents more commonly in women with conductive hearing loss in adulthood
describe the inheritance pattern of otosclerosis and what physiological condition makes it worse?
- auto domin inheritance with variable penetration
- pregnancy is when it is at its worst so treat it then!
what sign do you see on audiometry that points to otosclerosis?
classical dip (carharts notch) at 2kHz
what is the treatment of otosclerosis? give 2 options
hearing aid or stapedectomy
What is conductive deafness due to?
interference with the conduction of sound at any point from auricle to oval window
what is sensorineural deafness due to?
disease of the COCHLEA, AUDITORY NERVE OR BRAIN
what muscle underlies the posterior pillar of the fauces?
what muscle underlies the anterior pillar of the fauces? how is it related to gag reflex?
palatoglossus. mucosa is innervated by the 9th CN which carries afferent fibres for gag reflex. the efferent limb of the gag reflex is supplied by vagus nerve (CN10)
where is there a weakness in the pharynx that can cause something to cause dysphagia..? what is this something?!
between upper border of cricopharyngeus and lower border of inferior constrictor muscle of pharynx is a weak are called Killian's dehiscence. an outpouching here can cause PHARYNGEAL POUCH (Zenker's diverticulum)
which nerve supplies most muscles of pharygeal wall?
pharyngeal plexus from branches of vagus nerve
which muscle of pharynx is not supplied by vagus? and which nerve is it supplied by?
stylopharyngeus - glossopharyngeal nerve
A 53-year-old woman presents with a six-month history of a mass below the angle of the jaw on the right. It is gradually increasing in size and is mobile and firm to the touch. There is no associated pain or facial weakness. what investigation and why?
- excision biopsy. as unilateral parotid swelling likely pleomorphic adenoma.
- why not incisional biopsy? if carcinoma it may seed tumour in the wound
clinically how would you differentiate between pleomorphic adenoma and carcinoma of parotid?
carcinoma much more invasive and cause facial nerve palsy quickly
A 68-year-old man presents with a mass in the anterior triangle of the neck. It has increased in size over the last two months. It is soft, pulsatile and has an associated bruit. whats the differential and which investigation?
- carotid artery aneurysm or carotid body tumour (chemodectoma)
- inv: digital subtraction angiogram
46-year-old woman presents with a diffuse swelling in the anterior part of the neck. She also describes a hoarse voice. On examination, she has a diffuse multinodular goitre, bradycardia and slow-relaxing reflexes. which investigation?
ultrasound. why? to confirm typical multi nodular goitre architecture
A 27-year-old man describes intermittent painful swelling below his jaw. The pain and swelling is worse on eating. He is otherwise well. On examination, there is a small, tender swelling in the left submandibular region. what investigation?
sialogram. see stones in duct
A 72-year-old man presents with a hard, painless swelling in the anterior triangle of the neck. He has had a hoarse voice for two months. He is a lifelong smoker and drinks heavily. which investigation?
nasopharyngoscopy. why? as cervical LN may be the only sign of pharynx/larynx/H&N cancer
70-year-old man presents with hearing loss, bloodstained discharge from the ear and facial paralysis. what is the diagnosis?
squamous cell carcinoma of the ear canal. if middle ear is involved then get facial paralysis.
what is the treatment for SCC of ear canal?
- local excision,
- mastoidectomy with excision of the parotid gland and temporomandibular joint
- postoperative radiotherapy
what is the treatment of acute otitis media?
bed rest, analgesic, nasal decongestant, broad spec antibiotics to cover haemophilus and strep. if glue ear suspected go to hospital as middle ear could be permanently damaged - impaired language development
what is ramsay hunt syndrome?
herpes zoster infection of geniculate ganglion of facial nerve. deafness is early complication. treat early with aciclovir to prevent permanent damage to facial nerve
A 58-year-old woman with generalised discomfort and tenderness around and behind the ear. Movement of her neck is restricted and causes her to experience a similar pain. diagnosis?
- cervical spondylitis. can get referred pain to ear (otalgia).
- treat physio and anti inflamm analgesics
A 68-year-old man lifelong cigarette smoker complaining of worsening right-sided earache, a sore tongue and difficulty talking. diagnosis?
- SCC of tongue.
- OE find ulcer on right tongue
what is the first line management for traumatic perforation of tympanic membrane? and why?
watch and wait if no evidence of infection as most heal spontaneously. if after few months no healing then do myringoplasty
what is a branchial cyst? why is it there?
- retained elements of 2nd branchial cleft
- incomplete fusion of branchial arch system
when do branchial cysts present?
NOT at birth. at young adult
what are branchial cysts lined by?
what are branchial cysts sometimes surrounded by?
what do branchial cysts containing?
glary fluid with cholesterol crystals made by epithelium
where do you commonly find branchial cysts?
swelling on anterior border of SCM at the junction of upper and middle thirds
what is the treatment of branchial cysts and why?
- excised NOT aspirated.
- if aspirate, the epithelium is stil there and can continue to produce the cholesterol fluid. during aspiration it can get infected and fistula formation
what is a cholesteatoma?
keratinising squamous epithelium in middle ear cleft
causes of cholesteatoma
- congenital: rare
- acquired: primary - retraction; secondary - implantation
what is the surgical treatment of cholesteatoma
A 51-year-old man with poor ear hygiene complains of deafness after taking a shower. diagnosis?
with poor hygeine, showering pushes wax towards ear drum
A 24-year-old man presents complaining of right earache that worsened over the last 24 h, this
has now improved with a purulent discharge from the ear. diagnosis?
acute otitis media
A 24-year-old man presents with brown patches that have newly appeared on his trunk. ear probs. diagnosis?
acoustic neuroma (vestibular schwannoma) is associated with cafe au lait spots. sensorineural deafness
what kind of neck swelling moves out when you stick tongue out and why?
thyroglossal cyst as it is attached to the base of the tongue and therefore moves with protrusion of the tongue
where does chemodectoma arise and how to distinguish from carotid artery aneurysm
- CBT arises at bifurcation of carotid.
- no bruit in CBT but bruit in aneurysm
- CBT is firm but soft; aneurysm is fluctuant
how would you distinguish BPPV from Menieres?
- symptoms: BPPV no tinnitus or hearing loss
- Menieres no nystagmus
- examination: BPPV symptoms can be reproduced on examination by dix hallpike manoeuvre (rotate head 45 degrees and get rotatory nystagmus)
why do you get frontal sparing in UMNL of facial nerve?
- muscles of forehead are innvervated by both left and right sides of MOTOR CORTEX
- UMNL is above level of facial NUCLEUS and so you get only a bit of weakness of forehead muscles as still got innervation from contralateral side
- whereas LMNL directly affects facial nerve so get total facial weakness on that side
What is the common cause of Bell's palsy and how do we know?
viral infection of facial nerve. it is sudden onset and presents after URTI
treatment of bells palsy? and prognosis?
high dose oral steroids and most make full recovery
give causes of LMN facial nerve palsy
- LMN lesion = Bell's Palsy
- 1. infective: Herpes simplex 1, herpes zoster (Ramsay Hunt), Lyme (bilat, child), otitis media (child), cholesteatoma
- 2. neoplastic: posterior fossa tumour, parotid gland carcinoma
- 3. Neurological: Guillain Barre (bilat), MS, Mononeuropathy (DM, sarcoid, amyloid)
- 4. Sjogren's
- 5. Hypertension, eclampsia
give 6 causes of UMNL facial palsy
- 1. cerebrovascular event
- 2. MS
- 3. Syphilis
- 4. HIV
- 5. Vasculitides
- 6. Intracranial tumour
singer has been rehearsing loads and got hoarse voice. cause
vocal cord trauma. not 'singers nodules' - these are the cause of hoarseness PERSISTS
Give 5 causes of laryngeal nerve palsy?
- 1. iatrogenic: during thyroid surgery so always examine vocal cords formally before thyroid surgery for medico-legal reasons
- 2. anaplastic thyroid carcinoma: highly locally invasive into laryngeal nerve
- 3. syringomyelia
- 4. lung: apical TB or lung cancer
- 5. oesophagus: cancer
- 6. cervical LN: cancer
- 7. hypopharynx: cancer
- 8. aortic aneurysm
presentation of carcinoma of larynx
- male smoker
what is the most common cause of hoarseness lasting less than 3 weeks and how to investigate and treat?
- usually viral but if persists/severe do THROAT SWAB
- organisms: staph strep infection
- treat: oral penicillin V
what is the difference between exudative tonsillitis and quinsy?
- exudative tonsilitis: inflammed tonsils bilaterally, grey-white exudates on tonsils
- quinsy: unilateral peritonsillar abscess, pushes uvula away
how to distinguish between pleomorphic adenoma and parotid carcinoma
facial nerve involvement in carcinoma but not adenoma
how to distinguish between pleo adenoma of parotid and parotid abscess/inflammation?
- shape of adenoma quite distinct ball like but in abscess it wouldnt look as swollen it would be more tender
- overlying skin of adenoma is not inflamed and is normal
?which muscle is attached to the stylohyoid ligament and the lessor horn of the hyoid bone?
middle constrictor of pharynx
which muscle is attached to the oblique line on the thyroid cartilage?
inferior constrictor. contains Killian's dehiscence (p pouch)
most muscles of pharynx are innvervated by pharygeal plexus from vagus except for 2, which are these and what are their nerves?
- stylopharngeus - glossopharyngeal nerve
- tensor palati - medial pterygoid branch of trigeminal nerve
which muscle has a common raphé of origin with the buccinator muscle?
give 6 features of myxoedema
- myxoedema is hypothyroidism
- voice: deep and slow
- HR: bradycardia
- bowel: constipation
- reflexes: slow
- skin: thick coarse
- hair: thin
why do you get hoarse voice in pharyngeal pouch?
food and acid reflux
which nerve supplies all intrinsic laryngeal muscles except for one, name this too and its nerve
recurrent laryngeal nerve supplies all except CRICOTHYROID supplied by SUPERIOR laryngeal nerve
what does bilateral RLN palsy cause? (2things)
- 1. loss of voice
- 2. respiratory difficulty as cords held in neutral position
what are the 2 most common organisms for otitis media?
streptococcus and haemophilus
what are 2 main risk factors for oral cancer?
smoking and alcohol
what is the blood supply to UPPER NOSE?
ethmoidal arteries from internal carotid
most of nasal mucosa blood supply (apart from upper) is..
from external carotid artery branches: greater palatine, sphenopalatine, superior labial arteries
what are the most common causative organisms of acute sinusitis?
strep pneumoniae, haemophilus influenzae
whats the first line treatment of acute sinusitis?
broad spectrum antibiotics
name a syndrome that is a risk factor for sinusitis?
Kartagener's syndrome: cilial dysfunction and consequent inadequate sinus drainage
what are the most common type of malignant tumours of oral cavity?
squamous cell carcinoma
where are the 2 most common sites of oral cancer?
- lateral border of tongue
- floor of mouth
in acute tonsillitis should you give amoxicilin first line?
no as fear of maculopapular rash
what is the treatment of acute otitis media?
- 1. bed rest
- 2. analgesia
- 3. nasal decongestant
- 4. antibiotics: not usually needed expect in severe (as most resolve spont) but use amoxicillin, broad spec against strep pneum and haem influe
why do pt with glue ear/OME have to be referred to hospital?
ENT assessment as glue ear can lead to permanent damage to middle ear and impaired language development
what is the treatment of glue ear/OME?
- 1. watch and wait: as it will resolve spontaneously normally
- 2. balloon inflation treatment: to increase pressure and open ET for fluid drainage. or can buy Otovent an autoinflation kit
- 3. drainage and Grommet insertion: these fall out after 6-12 months as the ear drum grows
- 4. adenoidectomy: if recurrent glue ear and big adenoids
- 5. hearing aid: instead of Grommets, until the glue ear clears
what are the clinical features of ASOM (acute suppurative otitis media)?
- pus in middle ear
- otalgia (pain)
- perforated TM (sometimes)
- LMN facial nerve palsy. why? as facial nerve passes through middle ear, in otitis media it puts pressure on unprotected nerve
What are the complications of acute otitis media, both intra and extracranial?
- intracranial: meningitis, abscess, lateral/sigmoid sinus thrombosis
- facial nerve palsy, labyrinthitis, sensorineural deafness, mastoiditis
what are the sequelae of acute otitis media?
- 1. glue ear
- 2. TM perforation - giving bloody discharge
- 3. adhesions
- 4. tympanosclerosis
- 5. ossicular erosions
what is tinnitus?
auditory sensation of noise without external sound stimulation
what time of the day are symptoms of tinnitus worst?
at night as noise appears louder as there is no masking background noise
why should all cases of UNILATERAL tinnitus be referred to ENT?
may be acoustic neuroma (vestibular schwannoma)
treatment of tinnitus? (3 ways)
- 1. positive reassurance
- 2. background noise at night eg TV or radio
- 3. tinnitus masker (which makes white noise)
what is menieres disease and what is the likely cause?
- triad: DVT fluctuating deafness, vertigo, tinnitus
- aural fullness
- cause: excess endolymphatic fluid
- during acute episode: feel really ill, N+V
treatment of menieres disease? (C&S)
- conservative: avoid caffeine, salt, other trigger factors
- surgical: grommets, saccus decompression, gentamicin into middle ear cleft
- extreme: labyrnthectomy and vestibular nerve section
what is the presentation of acoustic neuroma? (3)
- slow onset UNILATERAL symptoms of:
- hearing loss
- +/- vertigo
as acoustic neuroma grows, what are the consequential symptoms?
- cranial nerve palsies: CN 6, 7, 8
- intracranial hypertension
investigations of suspected acoustic neuroma?
- clinical exam
- Pure tone audiometry - unilateral sensorineural hearing loss
treatment of acoustic neuroma?
- conservative: annual MRI growth
what is a cholesteatoma and what are its consequences?
- benign slow growing epithelial tumour
- causes progressive destruction of ossicles, labyrinth, facial nerve hence loss of hearing
- further consequences: brain abscess, meningitis, thrombosis of sigmoid sinus
how does HHT present? (2)
- facial telangiectasia
- recurrent epistaxis
things to ask for epistaxis history?
- meds: warfarin, aspirin
- blood dyscrasias in the family
what is allergic rhinitis?
type I hypersensitivity reaction to inhalged or ingested allergens
how does allergic rhinitis present? 4 things
- nasal blockage
what other disease do many people with rhinitis suffer from? and why is this likely?
- its the same pseudostratified ciliated columnar epithelium in nose and airways
things to look for on history and examination of allergic rhinitis?
- history: trigger factors, pets
- examination: nasal polyps
what is the treatment for allergic rhinitis?
- Conservative: avoid trigger factors
- medical: anti histamines, topical nasal steroids, nasal douche
investigations for allergic rhinitis?
- 1. skin prick tests for various allergens
- or 2. RAST radioallergosorbent test
what is the main symptoms of fronto-maxillary sinusitis? when does it usually develop?
- throbbing pain worse on bending forward
- develops after URTI
treatment of sinusitis?
- nasal decongestant
- analgesia as get facial pain
- topical nasal steroids
what are the CT changes of sinusitis?
the normally air filled cavitiies are now mucus filled
what are symptoms of chronic sinusitis?
- nasal obstruction
what is the main cause of non allergic rhinitis?
infectious: common cold RHINOVIRUS, adenovirus
what is a nasal polyp?
herniation of submucosa through the epithelium
what are nasal polyps associated with? (4)
- chronic sinusitis
- cystic fibrosis
- churg strauss (autoimmune vasculitis)
what are the symptoms of nasal polyps?
- nasal obstruction
- hyposmoia: loss of smell
what is the treatment of nasal polyps?
- medical: topical nasal steroids, nasal douche
- surgical: polypectomy
What are tonsils and adenoids and what is their role?
- consist of lymphoid tissue
- role: immune processing of substances we inhale and ingest
what are consequences of overproliferation of tonsils/adenoids?
- 1. infections
- 2 obstruction to postnasal space or oropharynx and then obstructive sleep apnoea
what is treatment of tonsillitis?
- GP oral antibiotics: penicillin +/- metronidazole
what is glandular fever? sign, who?
- viral cause of tonsillitis - EBV
- associated with kissing (contact)
- marked cervical lymphadenopathy in young adults
investigations of glandular fever?
- 1. WCC
- 2. monospot test detecting heterophile antibodies
- 3. LFT as can become jaundiced
treatment of glandular fever
AVOID ANTIBIOTICS ESPECIALLY: AMPICILLIN because of rash
what are the complications of glandular fever (2)
- 1. fatigue
- 2. splenic rupture - rare but fatal!
what are the complications of tonsilitis? (3)
- 1. Quinsy: peritonsillar abscess
- 2. Parapharyngeal abscess
- 3. Obstructive sleep apnoea if hypertrophy of tonsil
what are the symptoms of peritonsillar abscess (quinsy)?
- marked trismus (difficulty & ltd mouth opening)
- intense sore throat
what would u see OE quinsy?
- UNILATERAL tonsillar ENLARGEMENT
- bilateral tonsilitis
- may be cervical lymphadenopathy
treatment of quinsy?
- aspiration or incision and DRAINAGE (give LA spray before)
- iv antibiotics
if quinsy fails to improve after 2 days high dose iv antibiotics and patient is really unwell, what should you suspect? and what should you do?
- parapharyngeal abscess
- urgent CT from skullbase to diaphragm
- if abscess drain through neck
how does obstructive sleep apnoea present?
- marital disharmony
- loud snoring
- multiple nocturnal waking
- daytime somnolence
what features do you see on examination on person with OSA?
- overweight (BMI>25)
- large neck
- large tonsils
- long dependent uvula
- relatively small jaw
- voice is hyponasal
- can hear snoring at rest
- adenoid hypertrophy
how do you diagnose OSA?
- polysomnography showing more than 30 episodes of cessation of breathing for more than 10sec over a 7h period
- check if DESATURATION correlate with snoring
what are different treatments of OSA?
- conservative: weight loss, avoid alcohol, avoid sedatives at night
- dental positioning devices - double split to pull jaw forward so less obstruction (like mouth guard)
- surgery has limited role in selected cases - soft palate can be tightened or trimmed, can remove tonsils or adenoids if large
- advice not to drive!