Online learning module



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Online learning module

Welcome to the asynchronous formal learning for Year 4 ORL/ENT teaching.

You have been allocated 4 hours to complete this online module. Some questions in your exam will be sourced from this material.

The purpose of this online module is to give you a good overview of ORL conditions that you are likely to encounter in your early clinical practice.

Otorhinolaryngology has four sub-specialties:


  1. Head and Neck

  2. Laryngology

  3. Otology

  4. Rhinology

On the left hand side you can navigate through the teaching materials under each of these clinical topics.

Summary of objectives:

1. Spend a minimum of four hours learning from this module

2. Become comfortable with the principles in the basic sciences, diagnosis and management of common ORL diseases

3. Enjoy the module!


Contents


Head and Neck – page 2

  • Sore throat – page 2

  • Deep neck space infection – page 7

  • Neck lump - page 9

Rhinology – page 11

Laryngology – page 16



  • Airway – page 16

  • Voice – page 18

  • Swallow – page 20

Otology – page 23

  • Ear infections – page 23

  • Cholesteatoma – page 27

  • Hearing loss – page 29

  • Vertigo and tinnitus – page 33

Head and Neck

Sore Throat


Differential diagnosis for a sore throat:

Tonsillitis

Peritonsillar abscess (Quinsy)

Supraglottitis / Epiglottitis

Deep neck space infections

-------


And the following that will be covered elsewhere in the curriculum:

Pharyngitis, common cold, foreign body, dental infections


Tonsillitis


Tonsillitis is inflammation of the pharyngeal tonsils. The inflammation usually extends to the lingual tonsils and adenoids therefore pharyngotonsillitis and adenotonsillitis are synonymous with tonsillitis

Aetiology

Most commonly viral - adenovirus, rhinovirus, RSV, EBV

15 - 30% are bacterial - mostly group A beta-hemolytic Streptococcus pyogenes (GABHS).

Epidemiology


  • Tonsillitis most often occurs in children; however, the condition rarely occurs in children younger than 2 years.

  • Tonsillitis caused by Streptococcus species typically occurs in children aged 5-15 years

History

  • Fever

  • Sore throat

  • Halitosis (foul breath)

  • Dysphagia (difficulty swallowing)

  • Odynophagia (painful swallowing)

  • Mild airway obstruction e.g. mouth breathing


Examination

  1. Degree of respiratory distress

  2. Full examination of oral cavity including the oral mucosa, dentition, salivary ducts. In particular look for: tonsillar erythema, oedema +/- exudate (see pictures above)

  3. Tender cervical lymphadenopathy

  4. Flexible nasoendoscopy - especially if severe to assess for degree of airway obstruction

Possible complications of Streptococcal pharyngotonsillitis

Non-suppurative complications
Scarlet fever
Rheumatic fever
Post-streptococcal glomerulonephritis

Suppurative complications
Peritonsillar abscess (Quinsy)
Deep neck space infections
Cervical lymphadenitis
Management

1. ABC's


  • Airway secured

  • Fluid resuscitation

2. Antibiotics

  • for acute inpatients - Penicillin IV 2MU Q6h

  • for outpatients - Penicillin PO for 10 days

3. Steroids

  • Reserved for inpatients - usually Dexamethasone either 8mg stat or 8mg TDS for one day

4. Supportive therapy

  • Anti-emetics

  • Analgesia and antipyretics


EBV Tonsillitis


Consider infectious mononucleosis particularly when tonsillitis is accompanied by:

- tender lymph nodes
- splenomegaly
- severe lethargy
- white/gray membrane may cover tonsils that are infected with EBV (see image)

However, EBV diagnosis can only be confirmed via blood tests. The importance of this is that EBV tonsillitis takes longer to resolve and patients should avoid contact sport



Peritonsillar Abscess (Quinsy)


Each tonsil is surrounded by a capsule. It is in the potential space (peritonsillar space) between the tonsil and capsule that abscesses can form - a peritonsillar abscess, or in layman's terms, quinsy

IMPORTANT: the peritonsillar space is contiguous with several deeper spaces and infections can involve the parapharyngeal and retropharyngeal spaces (see deep neck space infections)
Compare these pictures above with the pictures shown in the tonsillitis section. What are the differences?

Note carefully the following:

  • Uvula deviation to contralateral side

  • Inferior and medial tonsil displacement

  • Localised fluctuance (easier to appreciate when examining a patient than in pictures)

  • Swelling of supratonsillar fold/soft palate rather than tonsil itself

Aetiology

Tonsillitis can progress to cellulitis and then via tissue necrosis and pus formation to a peritonsillar abscess


or starts via an infection of minor salivary glands

Microbiology:

  • A polymicrobial flora is isolated from peritonsillar abscesses

  • Predominant organisms are anaerobes

  • Aerobic organisms present are commonly Strep, S aureus and H influenzae

Epidemiology

Peritonsillar abscess (PTA) usually occurs in teens or young adults but may present earlier and occur in later adulthood




History

Symptoms are the same as for tonsillitis with a few other symptoms that are red flags for PTA and deep neck space infections:



  • Neck pain

  • Throat pain, more severe on the affected side +/- referred ear pain

  • Trismus (lock-jaw) - due to inflammation of chewing muscles

  • Voice change - in PTA pharyngeal edema and trismus can cause a "hot-potato" voice - as if the patient is struggling with a mouthful of hot food

Remember: nasty dental infections can mimic PTA therefore examine the oral cavity carefully

Examination

As for tonsillitis.


Apart from the visual findings as noted above:

  • Drooling

  • Trismus

  • More severe dehydration

Patients with quinsy should have a flexible nasoendoscopy/laryngoscopy performed to rule out epiglottitis
Investigations for tonsillitis and PTA

General:
1. FBC, U+E (especially if dehydrated)


2. Monospot test/heterophile antibody test - to rule out infectious mononucleosis

With PTA or if you suspect deep neck space infections:


1. Lateral neck X-ray
If clinically concerned or X-ray suggestive then proceed to CT scan

Management

Always first think ABC's: In severe circumstances endotracheal intubation or a surgical airway may be required.

The cornerstone of PTA treatment is: incision and drainage

In addition the treatment regime includes the same medication and considerations as for tonsillitis.

Patients with PTA tend to be more toxic - therefore require more IV fluid resus (and greater care)


Supraglottitis/Epiglottitis


Epiglottitis and supraglottitis are interchangeable terms meaning:

inflammation of structures above the insertion of the glottis in the oropharynx including the epiglottis, vallecula, arytenoids and aryepiglottic folds (see picture below for nasoendoscopic view of the larynx)

Aetiology

Haemophilus influenzae type b (Hib) used to be responsible for >90% of epiglottitis cases
Due to vaccination the incidence has dropped markedly

Now other bacterial pathogens are responsible for the majority of cases including Strep, Staph and a number of gram negative bacilli



A Danish study demonstrated an incidence of paediatric epiglottitis of 4.9 cases per 100,000 per year in the decade before Hib vaccination.

With the introduction of widespread Hib vaccination - 1996 to 2005 - an incidence of only 0.02 cases per 100,000 per year was seen. (1)
History

  • Sore throat

  • Odynophagia/dysphagia

  • Muffled voice - "Hot potato voice"

  • Adults may have had a preceding upper respiratory tract infection (URTI)

Always ask about vaccination if you suspect supraglottitis


Examination

  • "Toxic" appearance of patient

  • Sitting or leaning forward. Extreme = "Tripod position" - Sitting up on hands, with the tongue out and the head forward

  • Drooling/inability to handle secretions

  • Irritability

  • Stridor: A late finding indicating advanced airway obstruction

+ Muffled voice, cervical adenopathy, fever, respiratory distress, mild cough

Flexible laryngoscopy is required for diagnosis + assessment of airway (if patient will tolerate it)

Remember: The progression of supraglottitis can be rapid (i.e. over hours!)
Investigation

1. Lateral Neck XR - may be useful (see image below)


Most adults are stable and may safely undergo imaging. When clarking patients with possible epiglottitis, lateral neck XR can be a useful screening tool.

2. As mentioned above - judicious use of flexible nasoendoscopy

3. Blood cultures

This lateral neck X-ray demonstrates a classic radiographic finding in epiglottitis - the "thumb sign"


- This is due to swelling of the epiglottis
- The swelling of the epiglottis on the X-ray is shown by the blue dotted line - the left side is normal and the right has the abnormality

Management

1. Airway is the priority - ensure early ENT review. You should know where the surgical airway (cricothyrotomy) kit is.


Unstable patients/severe respiratory distress may need immediate intubation or surgical airway management.

If patient is stable they may still need monitoring in ICU.

Minimise distress - particularly important in paediatric patients.

2. Antibiotic - 1st choice is ceftriaxone

3. Supportive therapy
Analgesia, anti-emetics, IV fluid

Deep Neck Space Infections

The anatomy of the neck is complex. To understand the origin and spread of deep neck space infections (DNSI) a basic understanding of the anatomy is required.



Summary of anatomical concepts:

  • Spatial compartments in the neck are created by fascial planes

  • These spatial compartments can communicate with each other -> spread of infection

  • Anterior to the prevertebral fascia is the "danger space" that extends from the skull base to the diaphragm - making mediastinitis a possible complication of abscesses that spread into this space

  • There are a number of important structures in this area including blood vessels, nerves & bone that can become affected

Types of DNSI:
1. PTA/quinsy (see previous page)
2. Retropharyngeal
3. Parapharyngeal
4. Prevertebral
5. Submandibular (relatively superficial)

Challenge to diagnosis: DNSI may be covered by layers of unaffected tissues & therefore is hard to visualise and palpate

Etiology

DNSI are most commonly complications of pharyngitis or dental infection


Other causes include: sialadenitis, IVDU, malignancy

Note: DNSI is often a complication of an inadequately treated pharyngitis, dental abscess or tonsillitis

Important possible sequela of DNSI:



  1. Internal jugular vein thrombophlebitis (Lemierre Syndrome) - causes septic emboli and sepsis

  2. Mediastinitis - signalled by chest pain or widened mediastinum on CXR

Carotid artery rupture, meningitis and cavernous sinus thrombosis are rare.

History

  • Sore throat, dysphagia, odynophagia, trismus

  • Neck pain and pain on neck movement

  • Can have painful neck mass


Examination

  • Posterior pharynx erythema + swelling in retropharyngeal abscess

  • Medial displacement of tonsil and lateral pharyngeal wall in parapharyngeal abscess

  • Torticollis (holds neck in rotated position)

  • Tender lymphadenopathy

Findings suggesting complications:
- Neurological deficit - cranial nerves (eg. hoarseness from vocal cord paralysis with carotid sheath and X/recurrent laryngeal nerve involvement)
- Horner syndrome from involvement of the cervical sympathetic chain

Investigations

1. Lateral neck X-rays +/- CT scan

2. FBC, U+E

3. Blood cultures



Management

1. ABC's As with PTA/Quinsy the airway is of paramount importance.


Followed by IV fluid resus for the "C"

2. Antibiotics

3. Surgery - incision and drainage




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