This new edition of ENT: An Introduction and Practical Guide provides an essential introduction to the clinical examination, treatment and surgical procedures within ENT. It encompasses the conditions most commonly encountered in the emergency setting, on the ward and in the outpatient clinic.With its highly practical approach and stepbystep guid
ENT AN INTRODUCTION AND PRACTICAL GUIDE SECOND EDITION ENT AN INTRODUCTION AND PRACTICAL GUIDE SECOND EDITION EDITED BY James Russell Tysome MA PhD FRCS (ORL-HNS) Consultant ENT and Skull Base Surgeon Cambridge University Hospitals NHS Foundation Trust AND Rahul Govind Kanegaonkar FRCS (ORL-HNS) Consultant ENT Surgeon Medway NHS Foundation Trust Visiting Professor in Otorhinolaryngology Professor of Medical Innovation Canterbury Christ Church University CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2018 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S Government works Printed on acid-free paper International Standard Book Number-13: 978-1-138-19823-4 (Paperback) This book contains information obtained from authentic and highly regarded sources While all reasonable efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal to them and not necessarily reflect the views/opinions of the publishers The information or guidance contained in this book is intended for use by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines Because of the rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently verified The reader is strongly urged to consult the relevant national drug formulary and the drug companies’ and device or material manufacturers’ printed instructions, and their websites, before administering or utilizing any of the drugs, devices or materials mentioned in this book This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as to advise and treat patients appropriately The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint Except as permitted under U.S Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any 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& Francis Group, 2018 | Includes bibliographical references and index Identifiers: LCCN 2017019190 (print) | LCCN 2017019740 (ebook) | ISBN 9781315270524 (General eBook) | ISBN 9781351982337 (Adobe eBook) | ISBN 9781351982320 (ePub eBook) | ISBN 9781351982313 (Mobipocket eBook) | ISBN 9781138298149 (hardback : alk paper) | ISBN 9781138198234 (pbk : alk paper) Subjects: | MESH: Otorhinolaryngologic Surgical Procedures methods | Otorhinolaryngologic Diseases surgery Classification: LCC RF46.5 (ebook) | LCC RF46.5 (print) | NLM WV 168 | DDC 617.5/1 dc23 LC record available at https://lccn.loc.gov/2017019190 Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com Dedication This book is dedicated to Dipalee, Amee and Deven, and to Laura, George, Henry and Max CONTENTS Foreword Preface Introduction Contributors Clinical anatomy ix x xi xii Max Whittaker ENT examination 18 Ketan Desai Common ENT pathology 26 Ketan Desai 4 Epistaxis 40 Joanne Rimmer 5 Audiology 49 Neil Donnelly 6 Tonsillectomy 58 James Tysome 7 Adenoidectomy 62 Ketan Desai Grommet insertion 65 Rahul Kanegaonkar 9 Septoplasty 68 Joanne Rimmer 10 Septorhinoplasty 74 Joanne Rimmer 11 Turbinate surgery 77 Joanne Rimmer 12 Endoscopic sinus surgery (ESS) 80 Joanne Rimmer 13 Nasal polypectomy 84 Joanne Rimmer 14 Tympanoplasty Neil Donnelly and Olivia Kenyon 86 15 Mastoidectomy 92 Neil Donnelly and Olivia Kenyon 16 Stapedectomy 99 Neil Donnelly and Olivia Kenyon 17 Bone-anchored hearing aid 103 James Tysome 18 Panendoscopy 106 Ram Moorthy 19 Direct- and microlaryngoscopy 107 Ram Moorthy 20 Pharyngoscopy 109 Sonia Kumar 21 Rigid oesophagoscopy 111 Ram Moorthy 22 Examination of post nasal space 113 Sonia Kumar 23 Rigid bronchoscopy 114 Sonia Kumar 24 Submandibular gland excision 116 Ram Moorthy 25 Hemi- and total thyroidectomy 119 Ram Moorthy 26 Superficial parotidectomy 122 Ram Moorthy 27 Tracheostomy 125 Francis Vaz 28 Voice 132 Francis Vaz 29 Airway management 137 Francis Vaz 30 Radiology 140 Dipalee Durve and Kaggere Paramesh 31 Management of neck lumps 148 Francis Vaz 32 Vertigo and dizziness 152 Rahul Kanegaonkar Index viii Contents 161 FOREWORD The ‘Introduction to ENT’ course has now become an established and must-attend course for the novice ENT practitioner The synergistic blend of didactic teaching and practical skills training has allowed many junior trainees to raise the standard of care that they deliver to their ENT patients The course manual is now a ‘Bible’ for junior students in nursing and medicine, caring for patients on wards, clinics or in emergency rooms The Royal College of Surgeons has endorsed this course in the past and it continues to maintain a high standard for postgraduate training I strongly recommend this course to any trainee embarking on a career in ENT Khalid Ghufoor Otolaryngology Tutor Raven Department of Education The Royal College of Surgeons of England ix specific clinical investigation (Table 32.2) Dix–Hallpike testing is also required in every case to demonstrate any form of nystagmus, but in particular geotropic torsional nystagmus consistent with posterior semicircular canal BPPV Vertical or horizontal nystagmus, or nystagmus that does not fatigue, is unusual, and patients require MRI scanning to exclude central pathology It is essential to document the latency and duration of any nystagmus seen and whether the nystagmus settled completely A thorough assessment also includes lying and standing blood pressure recording and gait assessment SPECIAL INVESTIGATIONS All patients should undergo a pure tone audiogram and tympanometry A sensorineural asymmetry may suggest a cerebellopontine angle tumour, which must therefore be excluded with MRI internal auditory meatii Vestibular testing is required in the majority of subjects referred to a balance service (exceptions may include BPPV that settles completely following particle repositioning manoeuvres) Not only these investigations support a working diagnosis, but in approximately 5%−10% of cases reveal unexpected unilateral or bilateral peripheral vestibular hypofunction and guide vestibular rehabilitation As it is not possible to directly access the peripheral vestibular organs, an indirect assessment based on the vestibulo ocular reflex is generally used (Figure 32.2) Bithermal caloric testing remains a simple and valuable method of comparing lateral semicircular canal function Eye movements may be recorded with electrodes attached to the face, electronystagmography (ENG) or by videoing pupil movement, videonystagmography (VNG) Saccades, smooth pursuit and optokinetic movement may also be assessed with this recording method Additional tests include rotational chair and vestibular evoked myogenic potentials (VEMPs) Patients with a history and assessment in keeping with central pathology should also undergo an MRI scan to exclude a space-occupying lesion or demyelination Patients with chronic ear disease or suspected superior semicircular canal dehiscence require a fine-cut computed tomography scan of the temporal bones COMMON VESTIBULAR PATHOLOGY Listed below are common vestibular conditions amenable to treatment (Table 32.1) Management pathways are also illustrated in Figure 32.3 Benign paroxysmal positional vertigo (BPPV) This is the commonest cause of vertigo in all age groups Patients classically describe rotatory vertigo when rising or turning over in bed Although the vertigo lasts for seconds, they feel unsteady for a great deal longer, but are then able to go about their normal daily activities There is no associated hearing loss or tinnitus Spells last for days to weeks and usually settle spontaneously Patients often describe a previous head injury, episode of ‘labyrinthitis’ or a brief spell of environmental tilting (‘the floor suddenly came up to meet me’) Symptoms arise due to debris derived from the otoconial membrane of the utricle Head rotation results in this debris striking the delicate cupula of the posterior semicircular canal, profoundly 154 ENT: An Introduction and Practical Guide Lateral rectus Medial rectus Oculomotor nucleus Abducens nucleus Vestibular nucleus Neural firing rate Head turning Figure 32.2 The vestibulo ocular reflex As a result of head rotation, endolymph flow within the semicircular canals causes movement of the cupulae within the ampullae of the lateral semicircular canals and relative shearing of the underlying stereocilia Neural impulses increase on the right and decrease on the left Neural connections to the IIIrd and VIth cranial nuclei result in contraction of the left lateral rectus and right medial rectus to stabilize gaze Table 32.1 Common causes of dizziness (in order of frequency) ●● Benign paroxysmal positional vertigo (BPPV) ●● Acute peripheral vestibular deficit (labyrinthitis/ vestibular neuritis) ●● Vertiginous migraine ●● Multilevel vestibulopathy ●● Cholesteatoma (CSOM) ●● Hyperventilation syndrome ●● Menière’s disease ●● Vestibular schwannoma ●● Multiple sclerosis ●● Vertebrobasillar insufficiency ●● Superior semicircular canal dehiscence stimulating the associated hair cells and causing vertigo (Figure 32.2) The mismatch in input between each side that occurs may also result in nausea, vomiting and anxiety The most common form affects the posterior semicircular canal On Dix–Hallpike testing, following a short latency, geotropic (towards the ground) torsional nystagmus will gradually appear, increase in severity and gradually subside completely This will correlate well with the symptoms of vertigo experienced by the patient during the test Having confirmed the diagnosis, an Epley manoeuvre should be performed This Vertigo and dizziness 155 156 ENT: An Introduction and Practical Guide rehabilitation in those who fail to recover • Vestibular Acute peripheral vestibular deficit • PTA • FVT Continuous rotatory vertigo with persistent nystagmus, not associated with hearing loss nor tinnitus Nausea and vomiting restrictions • Antimigrainous Tx • Dietary Vertiginous migraine • PTA • MRI Vertigo or disequilibrium lasting two to four days associated with periods or, previous history of classic migraine then subsequent spells lasting days No associated hearing loss, nor tinnitus Patients prefer bed rest in a quiet darkened room temporal bones • PTA • CT scan Chronic ear discharge or intermittent ‘ear infections’ Otoscopy demonstrates TM retraction with keratin/debris rehabilitation • Physiotherapy Multilevel vestibulopathy intervention • Surgical Cholesteatoma EXCLUDE PSYCHOLOGICAL OVERLAY • PTA Intermittent disequilibrium on rapid movement History of poor vision, peripheral neuropathy, osteoarthritis behavioural therapy • Cognitive Hyperventilation syndrome • PTA • FVT ‘Lightheadedness’ due to rapid breathing Anxiety state Clinical examination, normal intervention • Salt-free diet • Bendrofluazide • Surgical Menière’s disease • PTA • MRI IAM’s • FVT Aural fullness, hearing loss, rotatory vertigo and tinnitus Hours with nausea and vomiting Nystagmus during episodes Sensorineural hearing loss assessment intervention • Surgical • Regular Acoustic neuroma • PTA • MRI IAM’s Sudden hearing loss or asymmetric sensorineural hearing loss Occasional episodes of disequilibrium or vertigo Figure 32.3 Management pathways for common vestibular pathology (PTA – pure tone audiometry; FVT – formal vestibular testing) • Epley manoeuvre pc-BPPV Rotatory vertigo, lasting seconds, on rising or turning over in bed Torsional fatigable nystagmus on Dix-Hallpike testing Vertigo, dizziness or giddiness is curative in approximately 90% of cases A repeat manoeuvre may on occasion be required Alternative particle repositioning manoeuvres for posterior semicircular canal BBPV include Brandt–Daroff (9) and Semont manoeuvres (10) Gans manoeuvre may be used if the anterior semicircular canal is involved (11) Acute peripheral vestibular deficit (labyrinthitis/vestibular neuritis) This relatively common cause of vertigo arises due to a sudden failure of one peripheral vestibular organ This results in labyrinthine asymmetry, and the sensory mismatch that occurs causes severe persistent rotatory vertigo and profuse vomiting Patients may describe a recent flu-like illness They classically wake up with severe continuous rotatory vertigo that persists for 3−5 days Initially, patients must lie still as any movement results in worsening symptoms Thereafter, movements may be tolerated, but compensation for normal activities may take weeks or months Prochlorperazine, a peripheral vestibular sedative, is indicated in this situation, but should be limited to days, as long-term use may limit central compensation and, hence, functional recovery Clinical examination may reveal rotation on Fukuda More reliable is the head thrust test, where a catch-up saccade may be evident (note Table 32.3) Table 32.2 Limitations of vestibular compensation Visual impairment Cataracts Poor visual acuity Eye movement disorders Peripheral vestibular system Prolonged vestibular sedative use (e.g prochlorperazine) Recurrent or progressive vestibular insults Proprioception Immobility Psychological factors Anxiety Depression Agoraphobia Central pathology Cerebrovascular disease Intracranial pathology Rehabilitation Delay in starting vestibular rehabilitation Poor motivation Patients who not compensate benefit from generic or customized physiotherapy Those with visual vertigo (over-reliance on visual input) benefit from combining physiotherapy exercises and visually stimulating environments (12) Those who fail to improve must be reassessed and possible limitations to compensation excluded (Table 32.2) Vertigo and dizziness 157 Table 32.3 The sensitivity and specificity of clinical tests used to identify peripheral vestibular hypofunction Clinical test Sensitivity (%) Specificity (%) Gait assessment 23–86 38–92 Halmagyi head thrust test 34–100 64–100 Head shake test 35–95 62–92 Romberg test 61–79 58–80 Stepping tests 50 61 Dix–Hallpike testing for PC-BPPV 79 75 Vestibular migraine Also known as vertiginous migraine, this common cause of vertigo produces spells of vertigo or disequilibrium that last for several days and, in women, are frequently cyclical as they are hormone related Patients often describe phonophobia or photophobia and prefer to rest in a quiet, darkened room This is not usually associated with hearing loss or tinnitus proprioceptive loss due to diabetes mellitus), in addition to central changes within the brain (e.g ischaemic episodes) may result in multilevel vestibulopathy Patients benefit from a combination of physiotherapy exercises (generic, customized or strength and balance exercises) and lifestyle changes (e.g the use of a walking stick, glasses or cataract correction) Cholesteatoma (CSOM) Although no abnormalities are likely to be found on clinical examination, ENG/VNG testing may support central changes All patients should undergo MRI scanning in order to exclude central pathology Squamous epithelium within the middle ear may expand to erode into the inner ear While most patients present with intermittent or chronic ear discharge and hearing loss, some also experience intermittent vertigo and unsteadiness Treatment consists of dietary changes (avoidance of chocolate, caffeine, red wine, cheese and processed meat) The majority of patients benefit from this approach alone, although some may also require tricyclic antidepressants, calcium channel blockers or beta-blockers Hyperventilation syndrome Multilevel vestibulopathy Dizziness and vertigo are common symptoms in elderly patients Unilateral decline in one sensory pathway may be compensated for centrally, with little or no functional loss A reduction in the quality and quantity of sensory information from multiple sensory pathways (e.g worsening vision, Hyperventilation associated with anxiety, may result in lightheadedness and dizziness In some, anxiety may be the residual effect of a previous vestibular insult that the patient may have compensated for Asking a patient to breathe rapidly through pursed lips can reproduce symptoms These patients benefit from cognitive behavioural therapy Ménière’s disease Often misdiagnosed, this very uncommon cause of vertigo arises due to expansion of the scala media compartment within the inner ear As a result Reissner’s membrane may intermittently rupture 158 ENT: An Introduction and Practical Guide resulting in mixing of perilymph and endolymph and toxic over excitation of the neuronal elements within the inner ear Attacks are unpredictable and severe An initial feeling of aural fullness is followed by hearing loss, severe rotatory vertigo and tinnitus A pure tone audiogram will demonstrate a sensorineural hearing loss, initially in the low frequencies in the affected ear and then, as attacks continue, hearing loss across all frequencies It is essential to exclude a central pathology (e.g a cerebellopontine angle tumour) and, hence, an MRI scan must be performed Bithermal calorics will reveal a peripheral vestibular weakness Attacks eventually subside but at the expense of the hearing in the affected ear Treatment includes sublingual prochlorperazine for acute episodes, and bendrofluazide or betahistine to reduce the frequency and severity of attacks For those not controlled medically, surgery may be indicated Procedures include grommet insertion, transtympanic gentamicin ablation, labyrinthectomy and vestibular nerve section Up to 50% of patients may develop bilateral disease Bilateral vestibular hypofunction results in severe oscillopsia, with patients wheelchair-bound and unable to move their heads Hence, vestibular destructive procedures should be avoided if possible OTHER CAUSES Other relatively uncommon conditions that may present with vertigo or dizziness include multiple sclerosis, vestibular schwannoma (Figure 32.4), and vertebrobasilar ischaemia In each an MRI scan is required to establish a diagnosis Superior semicircular canal dehiscence is a rare condition whereby a defect in the bony covering of the superior semicircular canal results in a third window through which a pressure wave may be transmitted from and into the intracranial cavity This not only results in momentary vertigo in response to loud sounds (Tullio’s phenomenon) but also results in patients hearing their eyes moving KEY POINTS: ●●An understanding of the sensory pathways and their central interpretation provides a valuable guide to the diagnosis and management of patients who complain of vertigo and dizziness ●●While a number of conditions exist that may result in vertiginous spells, treatment is either curative or enormously beneficial in the vast majority of patients ●●The commonest cause of vertigo, BPPV, should be excluded in all cases by Dix–Hallpike testing Figure 32.4 Right vestibular schwannoma Vertigo and dizziness 159 REFERENCES Shepard NT, Telian SA (1996a) Balance Disorder Patient Basic Anatomy and Physiology Review Singular Publishing Group, Inc The Royal College of General Practitioners and Office of Population Census and Surveys (1986) Morbidity Statistics from General Practice HMSO, London Blake AJ, Morgan K, Bendall MJ et al.(1988) Falls by elderly people at home: Prevalence and associated factors Age and Ageing 17: 365−72 Campbell AJ, Reinken J, Allan BC, Martinez GS (1981) Falls in old age: A study of frequency and related clinical factors Age and Ageing 10: 264−70 Stevens JA, Olson S (2000) Reducing falls and resulting hip fractures among older women MMWR Recomm Rep 49: 3−12 McKenna L, Hallam RS, Hinchcliffe R (1991) The prevalence of psychological disturbance in neurootology outpatients Clinical Otolaryngology 16: 452−6 7 Halmagyi GM, Curthoys IS (1988) A clinical sign of canal paresis Archives of Neurology 45: 737−9 Dix, R, Hallpike C (1952) The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system Annals of Otology, Rhinology and Laryngology 6: 987−1016 Brandt T, Daroff R (1980) Physical therapy for benign paroxysmal positional vertigo Archives of Otolaryngology 106: 484−5 10 Semont A, Freyss G, Vitte E (1988) Curing the BPPV with a liberatory maneuver Advances in Otorhinolaryngology 42: 290−3 11 Gans R (2000) Overview of BPPV: Treatment methodologies Hearing Review 7: 50−4 12 Pavlou M, Lingeswaran A, Davies RA et al (2004) Simulator based rehabilitation in refractory dizziness J Neurol 251: 983−95 160 ENT: An Introduction and Practical Guide INDEX A ABC, see Airway, Breathing, Circulation ABG, see Air–bone gap ABR, see Auditory brainstem responses Absorbable packs, 42 AC, see Air conduction Action potential (AP), 55 Acute mastoiditis, 28; see also ENT pathology Acute otitis media (AOM), 27; see also ENT pathology Acute peripheral vestibular deficit, 155, 157 Acute sinusitis, 32; see also ENT pathology Acute suppurative otitis media (ASOM), 29–30; see also Facial nerve palsy Adenoidal curettage, 62–63; see also Adenoidectomy Adenoidectomy, 62 adenoidal curettage, 62–63 indications, 62 operative technique, 62 preoperative review, 62 suction diathermy, 63–64 Advanced trauma life support (ATLS), 31 AEPs, see Auditory evoked potentials Air–bone gap (ABG), 51 Air conduction (AC), 20 Airway, Breathing, Circulation (ABC), 137 Airway management, 137 aetiology of airway obstruction, 138 airway, breathing, circulation, 137 compromised airway management, 137–139 Airway obstruction aetiology, 138 Anterior nasal packing, 44–45 Anterior posterior (AP), 36 AOM, see Acute otitis media AP, see Action potential; Anterior posterior Arterial blood supply to nose, 9, 41; see also Epistaxis ASOM, see Acute suppurative otitis media ASSR, see Auditory steady state responses Attico antrostomy, 93, 94 Audiology, 49, 57 auditory brainstem response in waves, 55 auditory evoked potentials, 55–56 behavioural audiometry, 50–53 hearing loss, 49 objective audiometry, 54–55 otoacoustic emissions, 56 speech audiometry, 53 tests of hearing, 49 Auditory brainstem responses (ABR), 55 Auditory canal, 1–2 Auditory evoked potentials (AEPs), 55–56; see also Audiology Auditory steady state responses (ASSR), 56 B BAHA, see Bone-anchored hearing aid Balancing function, 152–153 BC, see Bone conduction Behavioural audiometry, 50; see also Audiology air conduction thresholds, 50 audiogram interpretation, 52–53 bone conduction, 51 conductive hearing loss, 51 left conductive hearing loss, 52 left sensorineural hearing loss, 52 normal hearing, 52 pure tone audiometry, 50–51 right mixed hearing loss, 52 rules of masking, 51 symbols used in pure tone audiometry, 50 transcranial attenuation through air, 51 Bells palsy, 29; see also Facial nerve palsy Benign paroxysmal positional vertigo (BPPV), 152, 154–156 BIPP ribbon gauze packing of nasal cavity, 45 Bone-anchored hearing aid (BAHA), 103 complication, 105 indications, 103 operative procedure, 103–105 postoperative review, 105 preoperative review, 103 Bone conduction (BC), 20 Index 161 BPPV, see Benign paroxysmal positional vertigo Branchial cyst, 150–151 C CAEPs, see Cortical auditory evoked potentials Canal, wall up mastoidectomy, 93 CAT, see Combined approach tympanoplasty Cauliflower ear, see Pinna—haematoma Cautery, 43–44 Cerebrospinal fluid (CSF), 31, 71, 81 Cervical lymph nodes, 16 Chest x-ray (CXR), 115 Cholesteatoma, 158 surgery, 92 Chronic secretory otitis media (CSOM), 92 Clinical anatomy, cervical lymph nodes, 16 deep neck spaces, 17 ear, 1–5 facial nerve, 5–7 larynx, 14–15 nose, 7–11 oral cavity, 11–12 pharynx, 12–14 salivary glands, 15–16 sensory distribution of face, 17 thyroid and parathyroid glands, 15 CM, see Cochlear microphonic Cochlea, Cochlear microphonic (CM), 55 Combined approach tympanoplasty (CAT), 93, 96–98 Complication, 113 Compromised airway management, 137–139 Computed tomography axial views of neck, 142 162 Index of sinuses, 144 of temporal bone, 143–144 Continuous positive airway pressure (CPAP), 69 Contrast swallow, 141 Coronal section of paranasal sinuses, 10 Cortical auditory evoked potentials (CAEPs), 56 CPAP, see Continuous positive airway pressure Cricothyroidotomy, 126 CSF, see Cerebrospinal fluid CSOM, see Chronic secretory otitis media Cuffed tubes, 129 Cupula, CXR, see Chest x-ray D Deep neck spaces, 17 Direct-and microlaryngoscopy, 107 complication, 108 indications, 107 operative procedure, 107 postoperative review, 108 Distortion product OAEs (DPOAEs), 56 DPOAEs, see Distortion product OAEs E EAC, see External auditory canal Ear, canal, cochlea, coronal section of ossicles, cupula, Eustachian tube dysfunction, external auditory canal, 1–2 inner ear, 4, maculae, microsuction, 21–22 middle, pinna, right tympanic membrane, wax, 26 EBV, see Epstein–Barr virus ECochG, see Electrocochleogram Electrocochleogram (ECochG), 55 Electronystagmography (ENG), 154 Embolization, 46 Endoscopic sinus surgery (ESS), 80 to access middle meatus, 81 along anterior attachment of uncinate process., 82 complication, 83 indications, 80 middle meatal antrostomy and ethmoid bulla, 82 opening of left anterior ethmoid, 82 operative procedure, 80–82 postoperative review, 83 preoperative review, 80 removal of left uncinate, 82 Endotracheal tube (ET), 58 ENG, see Electronystagmography ENT examination, 18; see also Rinne and Weber tuning fork testing otoscopy, 18–19 pinna and postaural region examination, 18 right tympanic membrane examination, 19 ENT pathology, 26 acute mastoiditis, 28 acute otitis media, 27 acute sinusitis, 32 ear wax, 26 epiglottitis, 35 facial nerve palsy, 29–30 foreign bodies removal, 30, 31, 36 impacted wax, 26–27 leakage or loss of tracheoesophageal voice prosthesis, 37 nasal trauma, 32 otitis externa, 26 otitis media with effusion, 27 parapharyngeal abscess, 35 perichondritis, 28 periorbital cellulitis, 32–33 peritonsillar abscess, 34 pinna cellulitis, 28 pinna haematoma, 28 retropharyngeal abscess, 36–37 septal haematoma/abscess, 32 smoke inhalation, 35 sudden sensorineural hearing loss, 28–29 supraglottitis, 34 temporal bone fractures, 30–31 tonsillitis, 33 tympanic membrane trauma, 30 Epiglottitis, 35; see also ENT pathology Epistaxis, 40 aetiology, 40 anatomy, 40 anterior nasal packing, 44–45 arterial blood supply to nose, 41 BIPP ribbon gauze packing of nasal cavity, 45 cautery, 43–44 embolization, 46 examination, 42 hereditary haemorrhagic telangiectasia, 47 history, 41–42 inflated epistaxis balloon in situ, 45 insertion of nasal pack, 44 local and systemic causes of, 41 management, 42 nasal pack in situ, 44 posterior nasal packing, 45–46 surgical intervention, 46 treatment, 42 treatment algorithm for, 43 vessel ligation, 46 Epstein–Barr virus (EBV), 33 ESS, see Endoscopic sinus surgery ET, see Endotracheal tube Eustachian tube dysfunction, 3; see also Ear External auditory canal (EAC), 1–2, 122; see also Ear F Facial nerve, external branches of, function examination, 25 intratemporal course, Facial nerve palsy, 29; see also ENT pathology acute suppurative otitis media, 29–30 Bells palsy, 29 foreign bodies removal, 30, 31, 36 Ramsay Hunt syndrome, 29 trauma, 30 Fenestrated tubes, 130 Fine needle aspiration (FNA), 141 Fine needle aspiration cytology (FNAC), 119 FNA, see Fine needle aspiration FNAC, see Fine needle aspiration cytology G Glue ear, see Otitis media with effusion Grommet insertion, 65 complications, 66 indications, 65 operative procedure, 65 patient information and consent, 65 postoperative review and follow-up, 67 H Haemorrhagic polyp, 135 Heliox, 34; see also ENT pathology Hemi-and total thyroidectomy, 119 complication, 119 indications, 119 operative procedure, 119–121 postoperative review, 121 preoperative review, 119 Hereditary haemorrhagic telangiectasia (HHT), 40, 47 HHT, see Hereditary haemorrhagic telangiectasia HPV, see Human papilloma virus Human papilloma virus (HPV), 135 Hyperventilation syndrome, 158 I Impacted wax, 26–27; see also ENT pathology Inflated epistaxis balloon in situ, 45 Inner ear, 4, Intensive therapy unit (ITU), 126 ITU, see Intensive therapy unit K Kiesselbach’s plexus, 40; see also Epistaxis KTP, see Potassium titanyl phosphate L Laryngeal cancer, 134 Laryngeal papillomatosis, 135 Larynx, 14–15 Lateral soft tissue film, 140–141 Lateral surface of nasal cavity, Lazy-S incision, 123 Index 163 Leakage or loss of tracheoesophageal voice prosthesis, 37; see also ENT pathology Ludwig’s angina, 12; see also Oral cavity Lymphadenopathy, 149–150 Lymph nodes in neck, 142 CT axial views of neck, 142 CT of sinuses, 144 CT of temporal bone, 143–144 magnetic resonance imaging, 145 PET-CT, 146–147 M Maculae, Magnetic resonance imaging (MRI), 56 Mastoidectomy, 92 aims of surgery, 94 alternatives to surgery, 94 assessment, 92–94 Attico antrostomy, 93, 94 canal wall up mastoidectomy, 93 cholesteatoma surgery, 92 chronic secretory otitis media, 92 combined approach tympanoplasty, 96–98 complication, 94 indications, 92 modified radical mastoidectomy, 93 operative procedure, 94 Mastoiditis, acute, 28 Ménière’s disease, 158–159 Microlaryngoscopy, 136 Modified radical mastoidectomy, 93 MRI, see Magnetic resonance imaging Multilevel vestibulopathy, 158 Myringoplasty, 87 164 Index osteomeatal complex, 11 principal function, skeleton of nasal septum, N Nasal cavities, landmarks and external nasal skeleton, pack insertion, 44 pack in situ, 44 skeleton, trauma, 32; see also ENT pathology Nasal polypectomy, 84 complication, 85 indications, 84 operative procedure, 84–85 postoperative review, 85 preoperative review, 84 Nasolaryngoscopy, flexible, 22 National Institute for Health and Clinical Excellence (NICE), 65 Neck and facial nerve function examination, 24–25 Neck lump management, 148 branchial cyst, 150–151 examination, 148–149 history, 148 lymphadenopathy, 149–150 salivary gland tumours, 151 special investigations, 149 thyroglossal duct cyst, 150 thyroid masses, 151 treatment, 149 NICE, see National Institute for Health and Clinical Excellence Nose, arterial blood supply to, coronal section of paranasal sinuses, 10 lateral surface of nasal cavity, 9 lateral wall of nasal cavity, 10 nasal cavities, nasal landmarks and external nasal skeleton, nasal skeleton, olfactory mucosa, O OAEs, see Otoacoustic emissions Objective audiometry, 54–55; see also Audiology Obstructive sleep apnoea (OSA), 69 Oesophagogastroduodenoscopy (OGD), 36 OGD, see Oesophagogastro duodenoscopy Olfactory mucosa, OME, see Otitis media with effusion Operative procedure, 113 Oral cavity, 11 examination, 23–24 floor of mouth, 12 tongue, 11 OSA, see Obstructive sleep apnoea Osteomeatal complex, 11 Otitis externa, 26; see also ENT pathology Otitis media with effusion (OME), 27, 65; see also ENT pathology Otoacoustic emissions (OAEs), 56; see also Audiology Otoscopy, 18–19; see also ENT examination Outfracture of inferior turbinate, 77 P Panendoscopy, 106 Parapharyngeal abscess, 35; see also ENT pathology Parathyroid glands, 15 Parent’s kiss, 31 Parotid gland, 15 Percutaneus tracheostomy, 126 Perichondritis, 28; see also ENT pathology Periorbital cellulitis, 32–33; see also ENT pathology Peritonsillar abscess, 34; see also ENT pathology Perpendicular plate of the ethmoid (PPE), 71 Pharyngoscopy, 109 complication, 110 indications, 109 operative procedure, 109–110 postoperative review, 110 Pharynx, 12 right postnasal space, 13 sagittal section through head and neck, 13 stacked muscular bands, 12 Pinna, 1; see also Ear; ENT pathology cellulitis, 28 examination of, 18 haematoma, 28 PNS, see Postnasal space Posterior nasal packing, 45–46 Postnasal space (PNS), 106 Post nasal space examination, 113 Potassium titanyl phosphate (KTP), 47 PPE, see Perpendicular plate of the ethmoid Pure tone audiometry, 50–51; see also Audiology Q Quinsy, see Peritonsillar abscess R Radiofrequency turbinoplasty, 78 Radiology, 140 computed tomography axial views of neck, 142 computed tomography of temporal bone, 143–144 contrast swallow, 141 CT of sinuses, 144 lateral soft tissue film, 140–141 magnetic resonance imaging, 145 morphology of lymph nodes in neck, 142 PET-CT, 146–147 ultrasound neck, 141 Ramsay Hunt syndrome, 29; see also Facial nerve palsy Recurrent laryngeal nerve (RLN), 120 Reinke’s oedema, 133 Retropharyngeal abscess, 36–37; see also ENT pathology Rhinoscopy, anterior, 20 Right tympanic membrane, 2; see also Ear examination of, 19 Rigid bronchoscopy, 114 complication, 115 indications, 114 operative procedure, 114 postoperative review, 115 ventilating bronchoscope, 115 Rigid oesophagoscopy, 111 complication, 112 indications, 111 operative procedure, 111–112 postoperative review, 112 Rinne and Weber tuning fork testing, 19; see also ENT examination anterior rhinoscopy, 20 ear microsuction, 21–22 facial nerve function examination, 25 flexible nasolaryngoscopy, 22 interpretation, 20, 21 neck and facial nerve function examination, 24–25 oral cavity examination, 23–24 rigid endoscopy, 23 Rinne’s test, 20 Weber’s test, 20 Rinne’s test, 20 RLN, see Recurrent laryngeal nerve S Salivary glands, 15–16 tumours, 151 Scottish Intercollegiate Guidelines Network (SIGN), 58 Sensory distribution of face, 17 Septal haematoma/abscess, 32; see also ENT pathology Septoplasty, 68 continuous quilting suture of nasal septum, 72 freer elevator, 71 incisions for septoplasty, 70 incision Through septal cartilage, 71 indications, 68 infiltration of septal mucosa, 70 nasal septum, 68 operative procedure, 69–72 postoperative review, 72 septal deviation to left, 69 Septorhinoplasty, 74 complications, 76 dorsal hump removal, 75 indications, 74 intercartilaginous incision, 75 medial and lateral osteotomy, 75 operative procedure, 74–75 postoperative review, 76 preoperative review, 74 SIGN, see Scottish Intercollegiate Guidelines Network Singer’s nodules, 133 Skeleton of nasal septum, Smoke inhalation, 35; see also ENT pathology SMR, see Submucous resection Index 165 Sound pressure level (SPL), 50 SP, see Summating potential SPA, see Sphenopalatine artery Speech audiometry, 53; see also Audiology roll-over, 53 Sphenopalatine artery (SPA), 46 SPL, see Sound pressure level SSHL, see Sudden sensorineural hearing loss Stapedectomy, 99, 101 aims of surgery, 100 alternatives to surgery, 100 assessment, 99-100 complication, 100 operation, 101–102 postoperative review, 102 Submandibular gland excision, 116, 117 complication, 116 indications, 116 operative procedure, 116–118 postoperative review, 118 preoperative review, 116 Submucous resection (SMR), 68 Suction diathermy, 63–64; see also Adenoidectomy Sudden sensorineural hearing loss (SSHL), 28–29; see also ENT pathology Summating potential (SP), 55 Superficial parotidectomy, 122 complication, 122 external auditory canal, 122 indications, 122 Lazy-S incision, 123 operative procedure, 122–124 postoperative review, 124 preoperative review, 122 Supraglottitis, 34; see also ENT pathology Surgical tracheostomy, 126–127 T Temporal bone fractures, 30–31 TEOAEs, see Transient evoked OAEs 166 Index TEP, see Tracheoesophageal puncture Thyroglossal duct cyst, 150 Thyroid, 15 and parathyroid glands, 15 masses, 151 Tongue, 11; see also Oral cavity Tonsillectomy, 58 bipolar tonsillectomy, 59 operative procedure, 58, 60 postoperative review and follow-up, 60 post-tonsillectomy haemorrhage, 61 preoperative review, 58 Tonsillitis, 33; see also ENT pathology Tracheoesophageal puncture (TEP), 37 Tracheoesophageal voice prosthesis leakage or loss, 37 Tracheostomy, 125 changing tracheostomy tube, 130–131 cleaning inner tubes, 130 complication, 127–128 contraindictions, 131 cricothyroidotomy, 126 cuffed tubes, 129 dressings, 130 fenestrated tubes, 130 generating voice with, 131 indications, 125 percutaneus tracheostomy, 126 surgical tracheostomy, 126–127 transtracheal needle, 126 tube care and speaking valves, 128 tube with adjustable flange, 130 uncuffed tubes, 129–130 Transcranial attenuation through air, 51 Transient evoked OAEs (TEOAEs), 56 Transtracheal needle, 126 Turbinate surgery, 77 complication, 79 indications, 77 operative procedure, 77–79 outfracture of inferior turbinate, 77 postoperative review, 79 radiofrequency turbinoplasty, 78 turbinectomy, 78, 79 Turbinectomy, 78, 79 Tympanic membrane trauma, 30; see also ENT pathology Tympanogram, 54 Tympanometry, 54 Tympanoplasty, 86 alternatives to surgery, 87 complication, 87 indications, 86 myringoplasty, 87 operative procedure, 88–90 postoperative review, 91 preoperative review, 87 types of, 86 U UADT, see Upper aerodigestive tract Ultrasound neck, 141 Uncuffed tubes, 129–130 Upper aerodigestive tract (UADT), 132 Upper respiratory tract infection (URTI), 132 URTI, see Upper respiratory tract infection V Ventilating bronchoscope, 115 Vertigo and dizziness, 152 acute peripheral vestibular deficit, 155, 157 balance function, 152–153 benign paroxysmal positional vertigo, 152, 154–156 causes, 159 cholesteatoma, 158 examination, 153–154 history, 152–153 hyperventilation syndrome, 158 limitations of vestibular compensation, 157 management pathways for vestibular pathology, 156 Ménière’s disease, 158–159 multilevel vestibulopathy, 158 sensitivity and specificity of clinical tests, 158 special investigations, 154 vestibular migraine, 158 vestibular pathology, 155 vestibulo ocular reflex, 154 Vestibular compensation, limitations of, 157 Vestibular migraine, 158 Vestibular pathology, 155 management pathways for, 156 Vestibulo ocular reflex, 154 Videonystagmography (VNG), 154 VNG, see Videonystagmography Vocal cord cysts, 136 granuloma, 135–136 Vocal fold nodules, 133 palsy, 134 Voice, 132 examination, 133 haemorrhagic polyp, 135 history, 132–133 laryngeal cancer, 134 laryngeal papillomatosis, 135 microlaryngoscopy, 136 pathology, 133 Reinke’s oedema, 133 upper aerodigestive tract, 132 upper respiratory tract infection, 132 vocal cord cysts, 136 vocal cord granuloma, 135–136 vocal fold nodules, 133 vocal fold palsy, 134 W Weber’s test, 20 Woodruff’s plexus, 40; see also Epistaxis Index 167 ...ENT AN INTRODUCTION AND PRACTICAL GUIDE SECOND EDITION ENT AN INTRODUCTION AND PRACTICAL GUIDE SECOND EDITION EDITED BY James Russell Tysome MA PhD FRCS (ORL-HNS) Consultant ENT and Skull... the gland The submandibular gland is a mixed serous and mucous salivary gland and forms the majority of saliva production at rest Its superficial portion fills the space between the mandible and. .. within the substance of the parotid gland to separate it into Figure 1.18 The major salivary glands of the head and neck Submandibular gland Clinical anatomy 15 In addition, the retromandibular vein