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Is parotid serous or mucinous?
serous
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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
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which muscle does parotid duct pass forward over and which does it pierce?
anteriorly over masseter and pierces buccinator
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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
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where does parotid duct open?
on the mucous membrane of the cheek, opposite the 2nd UPPER MOLAR TOOTH
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how many lobes does the parotid gland have?
2 lobes superficial and deep (+/- accessory lobe). so important to look inside mouth for deep lobe
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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
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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
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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!
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what disease of parotid gland can cause facial paralysis?
malignant tumour of parotid gland which is highly invasive and quickly involves facial nerve.
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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
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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!
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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
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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!
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what sign do you see on audiometry that points to otosclerosis?
classical dip (carharts notch) at 2kHz
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what is the treatment of otosclerosis? give 2 options
hearing aid or stapedectomy
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What is conductive deafness due to?
interference with the conduction of sound at any point from auricle to oval window
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what is sensorineural deafness due to?
disease of the COCHLEA, AUDITORY NERVE OR BRAIN
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what muscle underlies the posterior pillar of the fauces?
palatopharyngeus
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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)
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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)
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which nerve supplies most muscles of pharygeal wall?
pharyngeal plexus from branches of vagus nerve
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which muscle of pharynx is not supplied by vagus? and which nerve is it supplied by?
stylopharyngeus - glossopharyngeal nerve
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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
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clinically how would you differentiate between pleomorphic adenoma and carcinoma of parotid?
carcinoma much more invasive and cause facial nerve palsy quickly
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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
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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
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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
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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
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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.
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what is the treatment for SCC of ear canal?
- local excision,
- mastoidectomy with excision of the parotid gland and temporomandibular joint
- postoperative radiotherapy
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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
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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
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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
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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
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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
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what is a branchial cyst? why is it there?
- retained elements of 2nd branchial cleft
- incomplete fusion of branchial arch system
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when do branchial cysts present?
NOT at birth. at young adult
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what are branchial cysts lined by?
squamous epithelium
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what are branchial cysts sometimes surrounded by?
lymphoid tissue
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what do branchial cysts containing?
glary fluid with cholesterol crystals made by epithelium
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where do you commonly find branchial cysts?
swelling on anterior border of SCM at the junction of upper and middle thirds
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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
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what is a cholesteatoma?
keratinising squamous epithelium in middle ear cleft
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causes of cholesteatoma
- congenital: rare
- acquired: primary - retraction; secondary - implantation
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what is the surgical treatment of cholesteatoma
cortical mastoidectomy
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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
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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
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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
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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
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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
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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)
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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
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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
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treatment of bells palsy? and prognosis?
high dose oral steroids and most make full recovery
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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
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give 6 causes of UMNL facial palsy
- 1. cerebrovascular event
- 2. MS
- 3. Syphilis
- 4. HIV
- 5. Vasculitides
- 6. Intracranial tumour
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singer has been rehearsing loads and got hoarse voice. cause
vocal cord trauma. not 'singers nodules' - these are the cause of hoarseness PERSISTS
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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
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presentation of carcinoma of larynx
- male smoker
- hoarseness
- stridor
- dysphagia
- pain
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what is the most common cause of hoarseness lasting less than 3 weeks and how to investigate and treat?
- laryngitis
- usually viral but if persists/severe do THROAT SWAB
- organisms: staph strep infection
- treat: oral penicillin V
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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
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how to distinguish between pleomorphic adenoma and parotid carcinoma
facial nerve involvement in carcinoma but not adenoma
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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
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?which muscle is attached to the stylohyoid ligament and the lessor horn of the hyoid bone?
middle constrictor of pharynx
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which muscle is attached to the oblique line on the thyroid cartilage?
inferior constrictor. contains Killian's dehiscence (p pouch)
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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
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which muscle has a common raphé of origin with the buccinator muscle?
superior constrictor
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give 6 features of myxoedema
- myxoedema is hypothyroidism
- voice: deep and slow
- HR: bradycardia
- bowel: constipation
- reflexes: slow
- skin: thick coarse
- hair: thin
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why do you get hoarse voice in pharyngeal pouch?
food and acid reflux
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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
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what does bilateral RLN palsy cause? (2things)
- 1. loss of voice
- 2. respiratory difficulty as cords held in neutral position
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what are the 2 most common organisms for otitis media?
streptococcus and haemophilus
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what are 2 main risk factors for oral cancer?
smoking and alcohol
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what is the blood supply to UPPER NOSE?
ethmoidal arteries from internal carotid
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most of nasal mucosa blood supply (apart from upper) is..
from external carotid artery branches: greater palatine, sphenopalatine, superior labial arteries
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what are the most common causative organisms of acute sinusitis?
strep pneumoniae, haemophilus influenzae
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whats the first line treatment of acute sinusitis?
broad spectrum antibiotics
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name a syndrome that is a risk factor for sinusitis?
Kartagener's syndrome: cilial dysfunction and consequent inadequate sinus drainage
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what are the most common type of malignant tumours of oral cavity?
squamous cell carcinoma
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where are the 2 most common sites of oral cancer?
- lateral border of tongue
- floor of mouth
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in acute tonsillitis should you give amoxicilin first line?
no as fear of maculopapular rash
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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
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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
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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
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what are the clinical features of ASOM (acute suppurative otitis media)?
- pus in middle ear
- fever
- otalgia (pain)
- deafness
- perforated TM (sometimes)
- LMN facial nerve palsy. why? as facial nerve passes through middle ear, in otitis media it puts pressure on unprotected nerve
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What are the complications of acute otitis media, both intra and extracranial?
- intracranial: meningitis, abscess, lateral/sigmoid sinus thrombosis
- extracranial:
- facial nerve palsy, labyrinthitis, sensorineural deafness, mastoiditis
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what are the sequelae of acute otitis media?
- 1. glue ear
- 2. TM perforation - giving bloody discharge
- 3. adhesions
- 4. tympanosclerosis
- 5. ossicular erosions
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what is tinnitus?
auditory sensation of noise without external sound stimulation
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what time of the day are symptoms of tinnitus worst?
at night as noise appears louder as there is no masking background noise
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why should all cases of UNILATERAL tinnitus be referred to ENT?
may be acoustic neuroma (vestibular schwannoma)
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treatment of tinnitus? (3 ways)
- 1. positive reassurance
- 2. background noise at night eg TV or radio
- 3. tinnitus masker (which makes white noise)
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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
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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
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what is the presentation of acoustic neuroma? (3)
- slow onset UNILATERAL symptoms of:
- hearing loss
- tinnitus
- +/- vertigo
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as acoustic neuroma grows, what are the consequential symptoms?
- headaches
- cranial nerve palsies: CN 6, 7, 8
- intracranial hypertension
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investigations of suspected acoustic neuroma?
- clinical exam
- Pure tone audiometry - unilateral sensorineural hearing loss
- MRI
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treatment of acoustic neuroma?
- conservative: annual MRI growth
- radiotherapy
- surgery
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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
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how does HHT present? (2)
- facial telangiectasia
- recurrent epistaxis
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things to ask for epistaxis history?
- trauma
- meds: warfarin, aspirin
- blood dyscrasias in the family
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what is allergic rhinitis?
type I hypersensitivity reaction to inhalged or ingested allergens
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how does allergic rhinitis present? 4 things
- itching
- sneezing
- rhinorrhoea
- nasal blockage
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what other disease do many people with rhinitis suffer from? and why is this likely?
- asthma
- its the same pseudostratified ciliated columnar epithelium in nose and airways
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things to look for on history and examination of allergic rhinitis?
- history: trigger factors, pets
- examination: nasal polyps
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what is the treatment for allergic rhinitis?
- Conservative: avoid trigger factors
- medical: anti histamines, topical nasal steroids, nasal douche
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investigations for allergic rhinitis?
- 1. skin prick tests for various allergens
- or 2. RAST radioallergosorbent test
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what is the main symptoms of fronto-maxillary sinusitis? when does it usually develop?
- throbbing pain worse on bending forward
- develops after URTI
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treatment of sinusitis?
- nasal decongestant
- antibiotics
- analgesia as get facial pain
- topical nasal steroids
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what are the CT changes of sinusitis?
the normally air filled cavitiies are now mucus filled
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what are symptoms of chronic sinusitis?
- nasal obstruction
- rhinorrhoea
- hyposmia
- PAIN
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what is the main cause of non allergic rhinitis?
infectious: common cold RHINOVIRUS, adenovirus
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what is a nasal polyp?
herniation of submucosa through the epithelium
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what are nasal polyps associated with? (4)
- chronic sinusitis
- asthma
- cystic fibrosis
- churg strauss (autoimmune vasculitis)
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what are the symptoms of nasal polyps?
- nasal obstruction
- hyposmoia: loss of smell
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what is the treatment of nasal polyps?
- medical: topical nasal steroids, nasal douche
- surgical: polypectomy
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What are tonsils and adenoids and what is their role?
- consist of lymphoid tissue
- role: immune processing of substances we inhale and ingest
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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
- analgesia
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what is glandular fever? sign, who?
- viral cause of tonsillitis - EBV
- associated with kissing (contact)
- marked cervical lymphadenopathy in young adults
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investigations of glandular fever?
- 1. WCC
- 2. monospot test detecting heterophile antibodies
- 3. LFT as can become jaundiced
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treatment of glandular fever
AVOID ANTIBIOTICS ESPECIALLY: AMPICILLIN because of rash
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what are the complications of glandular fever (2)
- 1. fatigue
- 2. splenic rupture - rare but fatal!
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what are the complications of tonsilitis? (3)
- 1. Quinsy: peritonsillar abscess
- 2. Parapharyngeal abscess
- 3. Obstructive sleep apnoea if hypertrophy of tonsil
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what are the symptoms of peritonsillar abscess (quinsy)?
- marked trismus (difficulty & ltd mouth opening)
- otalgia
- febrile
- dysphagia
- intense sore throat
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what would u see OE quinsy?
- UNILATERAL tonsillar ENLARGEMENT
- bilateral tonsilitis
- may be cervical lymphadenopathy
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treatment of quinsy?
- aspiration or incision and DRAINAGE (give LA spray before)
- ANALGESIA
- iv antibiotics
- fluids
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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
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how does obstructive sleep apnoea present?
- marital disharmony
- loud snoring
- multiple nocturnal waking
- daytime somnolence
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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
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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
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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)
- CPAP
- 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!
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